SKMT COVID19 Guidelines April 10
SKMT COVID19 Guidelines April 10
SKMT COVID19 Guidelines April 10
Prepared by the
Infection Control Committee
Shaukat Khanum Memorial Cancer Hospital and Research Centre
Shaukat Khanum Memorial Cancer Hospital & Research
Center
Infection Control Committee
Coronavirus Disease 2019 (COVID-19)
Contents
Section 1: 2
COVID-19 Basics, Outpatient Pathway and Testing
Background; Case definitions 2
Isolation precautions; COVID-19 screening 3
Pathway for patients with suspected COVID-19 in the outpatient setting 4
COVID-19 Testing 6
Camp COVID Patient flow, Cleaning of rooms and medical equipment used 7
for COVID-19 patients
Camp COVID PPE guidelines 8
Section 2:
COVID-19 Clinical Syndromes and Inpatient Management 9
Isolation precautions and PPE for COVID-19 patients 12
Transporting COVID-19 patients 13
Room allocation for COVID-19 patients 13
COVID-19 patients requiring medical procedures 13
COVID-19 visitor policy 14
COVID-19 patients and cardiopulmonary resuscitation 14
When can isolation precautions be discontinued? 14
What if there is strong clinical suspicion but test results are negative? 14
When can the patient be discharged? 14
What instructions must patients be given on discharge? 14
Section 3: 14
Personal Protective Equipment (PPE)
Recommendations for PPE use 16
Recommendations for PPE in the EAR, IPD 17
Recommendations for PPE in the ICU 18
Recommendations for staff in all clinical areas; Recommendations for PPE reuse 19
Section 4:
Frequently Asked Questions (FAQs) 21
What resources are these guidelines based on? 21
What is the policy for pregnant healthcare workers? 21
What should employees with cough/cold symptoms do? 21
How can hospital staff protect themselves from COVID-19? 21
Code blue: suspected/confirmed COVID-19; Codes in the EAR
Appendix A: Patient Under Investigation (PUI) Form 22
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Section 1: COVID-19 Basics, Outpatient Pathway and
Testing
Background
• Caused by SARS-COV-2, first identified in Wuhan, China in 12/2019
• Transmission: human-to-human
modes of transmission: contact and droplets
Case Definitions:
Suspect case
Case Definition (added point 2):
A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g.,
cough, shortness of breath), AND any of the following:
Probable case
1. A suspect case for whom testing for the COVID-19 virus is inconclusive
OR
2. A suspect case for whom testing could not be performed for any reason.
Confirmed case
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1. A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and
symptoms.
Definition of contact
A contact is a person who experienced any one of the following exposures during the 2 days
before and the 14 days after the onset of symptoms of a probable or confirmed case:
1. Face-to-face contact with a probable or confirmed case within 1 meter and for more than 15
minutes;
2. Direct physical contact with a probable or confirmed case;
3. Direct care for a patient with probable or confirmed COVID-19 disease without using proper
personal protective equipment;
OR
4. Other situations as indicated by local risk assessments.
Note: for confirmed asymptomatic cases, the period of contact is measured as the 2 days before
through the 14 days after the date on which the sample was taken which led to confirmation
Isolation Precautions:
Standard + contact+ droplet: for all patients
Standard+ contact+ airborne: for patients requiring aerosol-generating procedures e.g.
bronchoscopy, CPR, intubation, nasopharyngeal specimen collection, noninvasive ventilation,
airway suctioning, NG insertion, dental procedures ONLY. Any other procedures do not fall
under this list.
Eye protection: for all patients
COVID-19 Screening:
SKM-Lahore
9:00 am to 9:00 pm 7 days a week: Screening will be performed at designated COVID
screening counters outside the hospital
COVID Camp 24 hours, 7 days a week
PCOs inside the hospital will continue to screen all patients arriving at their counters
SKM-Peshawar:
8:00 am to 9:00 pm 7 days a week: Screening at designated COVID counters outside the
hospital
PCOs inside the hospital will continue to screen all patients arriving at their counters
For patients meeting the case definition, activate the plan for suspected COVID cases:
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Pathway for Patients with Suspected COVID-19 in the Outpatient Setting
Assess severity of
illness.
Does the patient
require admission
(O2 sats<94% on
YES room air and
bilateral chest NO
infiltrates)?
-Outpatient management
-Follow contact and droplet
-Inpatient management precautions during evaluation
-Allocate single room -Follow contact + airborne
-Follow contact and droplet precautions precautions for patients
-Follow contact and airborne precautions undergoing aersol-generating
for patients undergoing aerosol procedures*
generating precedures* -Use eye protection
-Use eye protection for all patients -Collect nasopharyngeal swab
-Collect nasopharyngeal swab for PCR ⴕ fro PCRⴕ
-Fill out PUI form -Fill out PUI form
-Discharge with supportive
medications
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PCO: patient care officer; PUI : person under investigation
*Aerosol generating procedures: nasopharyngeal sample collection, bronchoscopy, airway suctioning,
noninvasive ventilation, intubation, CPR, dental procedures, NG insertion, upper GI endoscopy
ⴕWear a simple surgical mask for nasopharyngeal samples collected in open air
All samples must be placed in a biohazard bag, then in a puncture proof container or a second biohazard
bag and transported to the lab.
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COVID-19 Testing
Who should be tested for COVID-19?
Patients meeting the case definition
What COVID-19 test are we performing?
PCR on nasopharyngeal swab
Nasopharyngeal swab must be collected as shown in the diagram below
Additionally, 5 ml of blood must be drawn in a purple top vial and transported to the lab for
storage as per NIH guidelines
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Cleaning of rooms and medical equipment used for COVID-19 patients
The virus can persist on surfaces for up to 72 hours. It is crucial to clean rooms and medical
equipment as per hospital policy for contact and droplet/airborne precautions where applicable
8
Camp COVID PPE
PPE for all staff:
Gowns: 1 gown per shift; if leaving Camp COVID, discard your gown and use a new one once
back in Camp Covid
Surgical masks: 1 mask per shift
Faceshield: 1 faceshield per shift; if leaving Camp COVID, discard your faceshield and use a new
one once back in Camp Covid
Gloves: change between patients
Plastic apron: change between patients
Nasopharyngeal sampling must be performed in open air for stable patients wearing “PPE for all
staff” listed above
For sick patients who cannot be moved out of the camp into open air for sampling:
wear a gown, gloves, faceshield, N95, surgical mask over N95; once a sample has been collected,
discard the surgical mask and save the N-95 for reuse
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Section 2: COVID-19- Clinical Management
Nasopharyngeal RT- PCR positive for SARS CoV2 but having no symptoms
Mild:
Presence of symptoms consistent with COVID such as fever, fatigue, cough (with or without sputum
production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache
without any hemodynamic compromise, need for oxygen or chest x-ray findings.
Moderate:
Hypoxia (oxygen saturation ≤ 94%) or mild infiltrate on chest x-ray. Persistent high-grade fever for >3
days. Absence of features suggestive of severe disease (listed below)
Severe
Fever, shortness of breath, signs/symptoms of respiratory tract infection and any of the following:
Adults
RR > 30 breaths/Min
Central cyanosis
Respiratory distress (unable to complete a sentence)
CURB score of more than 2
Confusion, agitation, restlessness
SpO2 ≤ 93% on Room air
Bilateral widespread infiltrates on CXR.
Clinically heart failure (gallop rhythm, raised JVP)
Oxygen Saturation/ FiO2 ratio less than 315
Evidence of heart failure (Raised JVP, Gallop rhythm)
Signs of shock: Delayed capillary refill; Cold, clammy peripheries; Mottled skin; Systolic BP less
than 90 or less than 40mm Hg of baseline in hypertensive; Urine output < 0.5 ml/kg/hr
Pediatric patients:
Patients with mild or asymptomatic disease who do not have adequate home arrangements or
do not consent to stay at home should be shifted to a dedicated isolation facility (as opposed to
a hospital)
However, the following should be considered for hospital admission for observation if resources
allow.
1- Immunosuppressed (e.g. HIV, on long term steroids or other immunosuppression)
2- Age greater than or equal to 60 years
3- Co-morbid conditions: Heart Failure, Decompensated Liver Disease, Structural Lung Disease,
Uncontrolled Diabetes, Chronic Kidney Disease
If the patients cannot be admitted then clear instructions must be given to call if any worsening
occurs.
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Management
Management guidelines for COVID-19 Disease are evolving rapidly. Treating physicians should consult an
infectious disease specialist. All management should be carried out only by a registered medical
practitioner.
CBC
Electrolytes and serum creatinine
Chest X-ray
Treatment
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1. Adults: Chloroquine 500 mg BD x 10 days; Pediatrics (Loading:10mg base/kg Maintenance:
5mg base/kg once daily Loading x 10 days)
2. Hydroxychloroquine sulfate 200 mg, three times per day x 10 days
On therapy, QT-interval must be monitored; especially if other medications are being
administered which prolong the QT-interval.
Treatment
1. Empiric antibiotics may be considered if a secondary bacterial pneumonia is suspected (e.g. if raised
white blood cell count).
2. In patients with ARDS who are intubated, use conservative fluid management.
3. Cardiac impairment has been described and diuresis may be considered after consultation with
cardiology.
4. Do not give high-dose systemic corticosteroids or other adjunctive therapies.
5. Implement mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight, PBW)
and lower inspiratory pressures (plateau pressure < 30 cmH2O).
6. Finally, if expertise is available, in adults with severe ARDS, prone ventilation for 12–16 hours per day
is recommended.
There is no current evidence from studies to recommend any specific anti-COVID-19 treatment
for patients with suspected or confirmed COVID-19 infection. Based on the best available
evidence, treatment with either of the following can be started:
1. Adults: Chloroquine 500 mg BD x 10 days; Pediatrics (Loading: 10mg base/kg Maintenance:
5mg base/kg once daily Loading x 10 days)
2. Hydroxychloroquine sulfate 200 mg, three times per day during ten days
In addition other treatment options, which may be considered, include:
Lopinavir/ritonavir o 400/100mg BID 14 days
However these medications have considerable adverse effects, have limited available and
unclear efficacy. Consultation with an Infectious Diseases Specialist is mandatory prior to
prescribing.
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Standard+ contact+ airborne: for COVID-19 patients admitted in the ICU and those requiring
aerosol-generating procedures e.g. bronchoscopy, CPR, intubation, nasopharyngeal specimen
collection, noninvasive ventilation, airway suctioning, dental procedures, NG insertion, upper GI
endoscopy.
Eye protection: for all patients
To minimize exposure to airborne droplet nuclei, N-95 masks must form a tight seal around the
nose and mouth. Facial hair present along the edges of the mask prevents formation of this seal
and results in exposure to airborne infections.
Since specialized respirators are not available at our facility, staff members with
beards/sideburns/moustaches, who are expected to perform or assist with aerosol generating
procedures, or care for patients in the ICU or the floor must ensure that the area of the mask
seal is clean shaven
The virus can persist on surfaces for up to 72 hours. Therefore, it is crucial to clean rooms and
medical equipment as per hospital policy for contact and droplet/airborne precautions where
applicable
PPE guidelines must be followed by ALL staff members entering patient rooms
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5. Patients with suspected or confirmed COVID-19 requiring medical
procedures
All elective procedures must be cancelled to minimize transport and avoid unnecessary
exposure to hospital staff and other patients
9. What if there is strong clinical suspicion for COVID-19 but the test
results are negative?
Continue isolation precautions and repeat nasopharyngeal PCR in 3 days
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Section 3: Personal Protective Equipment (PPE)
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PPE Guidelines for EAR, IPD, ICU and other Clinical Areas
Follow standard precautions and strictly adhere to the 5 moments of hand hygiene for patients in all
clinical areas
EAR
All Staff:
Immediately move to an isolation room and follow droplet and contact precautions; use eye
protection
PPE includes gloves, gown, surgical mask, eye protection
IPD
Suspected cases must be placed in individual isolation rooms
Staff caring for suspected or confirmed COVID-19 patients undergoing aerosol generating
proceduresⴕ:
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PPE includes gloves, gown, N-95 mask*, faceshield/goggles^
ICU
Staff caring for suspected or confirmed COVID-19 patients in the ICU:
^Disinfect goggles with alcohol wipes before and after use. Following use, goggles must be placed in
designated drawers in isolation trolleys to be used by the next person
*N-95
N-95 masks may be obtained from unit coordinators (UCs). UCs must maintain a record of employees
who have been issued N-95 masks with the date the mask was issued.
Write your employee code on the mask prior to use
Write employee code on a paper bag prior to use and leave on the isolation trolley. These may be
obtained from unit coordinators covering the shift (image on page 18)
Wear a surgical mask on top of the N-95 to prevent mask contamination.
Following use, discard the surgical mask
Remove the N-95 mask carefully, without touching the front surface and place in the paper bag
Masks may be reused for up to 7 days or unless visibly soiled or damaged. If your mask is damaged, or
visibly soiled or no long forms a tight seal around your face and mouth, you must notify the UC and
submit the used mask to obtain a new N-95 mask.
N95 masks worn during intubation cannot be reused and must be discarded. Please note that CDC
currently recommends that masks not be reused following any aerosol generating procedures; however,
given the regional and global shortage of N-95 masks, you may continue to reuse N-95 masks worn
during aerosol generating procedures (other than intubation) as long as you wear a surgical mask on top
of the N-95.
Yellow bins for clinical waste must be placed inside and outside patients’ rooms
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If multiple patients with confirmed COVID-19 need to be seen:
do not remove goggles and mask between patients
perform hand hygiene before and after seeing patients
change gown and gloves between patients
ii) N-95
N-95 masks may be obtained from unit coordinators (UCs). UCs must maintain a record of employees
who have been issued N-95 masks with the date the mask was issued.
Write your employee code on the mask prior to use
Write employee code on a paper bag prior to use and leave on the isolation trolley. These may be
obtained from unit coordinators covering the shift (image on page 18)
Wear a surgical mask on top of the N-95 to prevent mask contamination.
Following use, discard the surgical mask
Remove the N-95 mask carefully, without touching the front surface and place in the paper bag
Masks may be reused for up to 7 days or unless visibly soiled or damaged. If your mask is damaged, or
visibly soiled or no long forms a tight seal around your face and mouth, you must notify the UC and
submit the used mask to obtain a new N-95 mask.
N95 masks worn during intubation cannot be reused and must be discarded. Please note that CDC
currently recommends that masks not be reused following any aerosol generating procedures; however,
20
given the regional and global shortage of N-95 masks, you may continue to reuse N-95 masks worn
during aerosol generating procedures (other than intubation) as long as you wear a surgical mask on top
of the N-95.
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Section 4: Frequently Asked Questions (FAQs)
1. What resources are these guidelines based on?
• CDC, WHO, NHS
5. What is the policy on code blue situations where the patient is a suspected or
known cases of COVID-19, or the COVID-19 infectivity status is unknown e.g
patients who are pulseless or code soon after arrival in the EAR?
• Wear gloves, gown, mask, N-95, faceshield or goggles. Do not participate in codes without the
appropriate PPE.
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Appendix A: Patient Under Investigation (PUI) Form
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Patient Under investigation (PUI) Form: Coronavirus Disease (COVID-19)
Shaukat Khanum Memorial Cancer Hospital & Research Centre
Patient first name _______________ Patient last name ___________________ Patient date of birth ______________________
Sex ☐ M ☐ F Nationality ___________________Place of Residence ________________________________________________
Patient NIC number____________________________Contact # _____________________________Marital Status:_____________
MR # (if generated) _________________________________ Screening date______________________________________
Physician’s name ___________________________________ Employee Code number_____________________________
PUI Criteria
Date of symptom onset___________________________________________________
Does the patient have the following signs and symptoms (check all that apply)?
☐ Fever1 ☐ Cough ☐ Sore throat ☐ Shortness of breath
Does the patient have these additional signs and symptoms (check all that apply)?
☐ Chills ☐ Headache ☐ Muscle aches ☐ Vomiting ☐ Abdominal pain ☐ Diarrhea ☐ Other, Specify_______________
Any International travel over the past 14 days before symptom onset
Country name:______________________________________ ☐ Y ☐ N ☐ Unknown
Date traveled to: ___________________ Date traveled from: _________________________
Date arrived in Pakistan: ______________________________
Have close contact2 with a person under investigation for COVID-19? ☐ Y ☐ N ☐ Unknown
Have close contact2 with a laboratory-confirmed COVID-19 case? ☐ Y ☐ N ☐ Unknown
In which country was the case diagnosed with COVID-19? ______________________________
Have close contact2 with an individual returning from international travel? ☐ Y ☐ N ☐ Unknown
Which country did the contact return from? ______________________________
Additional Patient Information
Is the patient a health care worker? ☐ Y ☐ N ☐ Unknown
Have history of being in a healthcare facility (as a patient, worker, or visitor)? ☐ Y ☐ N ☐ Unknown
Care for a COVID-19 patient? ☐ Y ☐ N ☐ Unknown
Diagnosis (select all that apply): Pneumonia (clinical or radiologic) ☐ Y ☐ N Acute respiratory distress syndrome ☐ Y ☐ N
Comorbid conditions (check all that apply): ☐ None ☐ Unknown ☐ Pregnancy ☐ Diabetes ☐ Cardiac disease ☐ Hypertension
☐ Chronic pulmonary disease ☐ Chronic kidney disease ☐ Chronic liver disease ☐ Immunocompromised
☐ Cancer, specify type
☐ Other, specify
Vital Signs: Temp: __________ Pulse: _________ RR: __________BP: __________ SpO2:__________Chest exam: _________________
Does the patient have another diagnosis/etiology for their respiratory illness? ☐ Y, Specify______________ ☐ N ☐ Unknown
1 Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain medications. Clinical judgement should be used to guide
testing of patients in such situations
2 Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household
members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g.,
being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as
walking by a person, are considered low risk and do not constitute close contact
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