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Standard Operating Protocols: COVID-19
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This document is neither peer-reviewed nor medically or scientifically vetted. It features information from
different websites and sources noted in the References section, including the official resources of WHO, Center
for Disease Control and Prevention (CDC) and European Centre for Disease Prevention and Control (ECDC). The
information and guidance in this document may be used only by medical and paramedical practitioners, and
other medical professionals engaged. For detailed guidance on topics covered in this document, please refer to
the sources mentioned in the References section. This document has not been approved by any authority or
regulator, but has been reviewed by a Consultant for National Accreditation Board for Hospitals & Healthcare
Providers (NABH), India. Usage and reference to the contents of this document shall be at the entire discretion
and judgement of the user. The organisations involved in gathering the information for preparing this document
shall not be responsible in any way for any loss or damage caused due to the usage of the contents of this
document.
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ACKNOWLEDGMENTS
We would like to thank the following organisations for contributing to this document:
CDC Group plc is the UK’s development finance institution and not the US Centers for Disease Control and
Prevention (CDC). This guidance does not constitute medical advice and is not a substitute for professional advice
from international public health organisations such as the World Health Organisation (WHO), national public
health authorities, and national governments, which should be consulted for qualified and more detailed
information in relation to health care and infection risk.
This document has been prepared by Areté Advisors with the financial support of CDC group. It does not
necessarily reflect the opinions of CDC Group. CDC Group is not responsible for its development and makes no
representations or warranties as to, and accepts no liability for, the accuracy of any information contained in this
document or for any interpretation or any use that may be made of the information contained therein.
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CONTENTS
Acknowledgments .................................................................................................................................................. 3
Contents ................................................................................................................................................................. 4
1. Executive summary ........................................................................................................................................ 6
2. Types of COVID-dedicated facilities ............................................................................................................... 9
3. Space routing in COVID facilities .................................................................................................................... 9
4. Mechanical, electrical and plumbing (MEP) modifications .......................................................................... 11
4.1. Heating, ventilation, air conditioning (HVAC): areas with infected patients including triage and
radiology........................................................................................................................................................... 11
4.2. HVAC: isolation wards ......................................................................................................................... 12
4.3. HVAC: other areas ............................................................................................................................... 13
5. Visitor restriction policy ............................................................................................................................... 13
6. Patient flow management ........................................................................................................................... 16
6.1. Outpatient management .................................................................................................................... 16
6.2. Triage – for early recognition of patients with COVID-19 ................................................................... 18
6.3. Admission criteria ............................................................................................................................... 19
6.4. Diagnosis ............................................................................................................................................. 20
6.5. Inpatient management ....................................................................................................................... 21
6.6. Discharge and follow-up ..................................................................................................................... 22
6.7. Protocols after death .......................................................................................................................... 23
7. Infection prevention and control ................................................................................................................. 25
7.1. Standard precautions .......................................................................................................................... 25
7.2. Empiric additional precautions ........................................................................................................... 27
7.3. Administrative controls ....................................................................................................................... 28
7.4. Environment and engineering controls ............................................................................................... 28
7.5. Procedure for remedial actions against occupational exposure to COVID-19 .................................... 29
8. Personal Protective Equipment (PPE) .......................................................................................................... 30
8.1. PPE components… ............................................................................................................................... 30
8.2. PPE requirement ................................................................................................................................. 31
8.3. Donning PPE ........................................................................................................................................ 33
8.4. Doffing PPE .......................................................................................................................................... 34
8.5. Guidelines for limited use and conservation of PPE ........................................................................... 36
9. Environmental cleaning ............................................................................................................................... 37
9.1. Disinfection of isolation ward ............................................................................................................. 37
9.2. Disinfection of high-touch surfaces..................................................................................................... 39
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9.3. Disposal of blood and body fluid spills ................................................................................................ 40
9.4. Disinfection of reusable medical equipment and devices .................................................................. 40
9.5. Disinfection of infectious fabrics ......................................................................................................... 41
9.6. Disposal of biomedical waste .............................................................................................................. 41
10. Minimising staff exposure ....................................................................................................................... 43
11. Staff training ............................................................................................................................................ 43
11.1. Training requirements and duration ................................................................................................... 43
11.2. Training courses .................................................................................................................................. 46
12. Preparation for surge inflow ................................................................................................................... 46
12.1. Mapping workforce expansion potential ............................................................................................ 46
12.2. Additional roles and responsibilites .................................................................................................... 47
13. Staff mental health .................................................................................................................................. 49
14. Appendix - checklists ............................................................................................................................... 49
Facilities and infrastructure checklist: COVID-19 facility.................................................................................. 49
Staff preparedness and planning ..................................................................................................................... 54
15. References ............................................................................................................................................... 64
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1. EXECUTIVE SUMMARY
Healthcare facilities across the globe are at the forefront of managing the COVID-19 pandemic. This has placed
tremendous stress on healthcare facilities and the disease has very quickly overwhelmed healthcare systems in
many countries.
Healthcare professionals are one of the most at-risk groups for contracting the disease. As of April 23 2020, an
estimated 21,800 healthcare workers had contracted the disease in the US alone. In India, hospitals have
repeatedly emerged as coronavirus infection hotspots. Therefore, it is important that, while treating patients,
hospitals have adequate standard operating protocols (SOPs) that ensure practitioner and patient safety.
While health agencies such as the WHO and country-specific disease control and health departments are
regularly issuing COVID-19-related guidelines, the information is disaggregated and often hard to track for time-
poor healthcare practitioners and administrators. This document, prepared by Arete Advisors on behalf of CDC
Group, is a comprehensive guide to help healthcare facilities plan and prepare for the pandemic.
Based on guidelines from various international organisations including WHO, ECDC, CDCP, this guide covers
three major aspects of preparedness for COVID-19 in detail:
1. Facility planning
2. Clinical and non-clinical protocols
3. Human resource management
It acknowledges the potential limited resources of PPE and other equipment in some parts of the world. It also
includes learnings from hospitals in India that may be useful for those operating in other developing and
underdeveloped nations. We have also compiled several checklists for healthcare facilities to track and audit
their preparedness.
Facility planning
Facility planning is an essential step to ensure isolation of infected cases and minimise transmission of the
coronavirus through segregation of COVID-19 and non-COVID-19 patients. This section includes guidelines on
the following:
• Setting up a triage for screening patients, introducing a visitor restriction policy, and setting up a
dedicated isolation ward and intensive care unit (ICU) for COVID-19 patients.
• Space routing within the facility by earmarking unidirectional pathways for movement of staff, patients,
medical consumables and contaminated items.
• Facility changes needed to protect health and care professionals (HCPs) and front desk staff.
• Configuring heating, ventilation, and air conditioning (HVAC) requirements in various areas of the
facility.
Clinical and non-clinical protocols
Clinical and non-clinical SOPs will ensure all staff are aware of the day-to-day activities expected of them, as well
as any additional precautions required for managing patients diagnosed with COVID-19. Guidelines include
patient flow management and infection prevention and control within the facility, including:
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• Management of patients starting from triage to discharge or demise of the patient. Guidelines for
treatment of patients have been excluded as we believe this is best left to the discretion of medical
practitioners.
• Protocols for cleaning and disinfectation of isolation wards and high-touch surfaces, disposal of blood
and body fluid spills, handling of infectious fabrics and disposal of biomedical waste.
• Personnel protection management including self-monitoring for symtoms, observation of hand hygiene
and respiratory hygiene and use of PPE.
• Due to the limited availability of PPE, these guidelines adopt a rational approach to PPE use, while
keeping the risk of contamination to a minimum.
Human resource management
In any healthcare facility, clinical and non-clinical staff play the most important role in managing the pandemic.
While it is crucial to ensure staff are well trained in all protocols designed for infection control, it is also important
to ensure their physical as well as psychological wellbeing. This document includes guidelines for staff rostering
to minimise exposure to the infection, training requirements for routine as well as non-routine activities, and
the available avenues for training. In addition, facilities need to prepare a contingency plan for surge inflow by
outlining potential workforce expansion and additional roles and responsibilities taken up by various members
of staff.
While these guidelines act as a overarching principle for preparing healthcare facilities, user discretion is
necessary for their adoption in any particular context. Local government policies should take precedence over
suggested guidelines, wherever applicable.
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Standard Operating Protocols: COVID-19
Facility planning
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This section includes guidelines on infrastructure and space management in hospitals during the COVID-19
outbreak. It is intended to help hospitals allocate isolation areas for COVID-19 patients and minimise the
scope of transmission by limiting movement within the hospital of staff, patients, visitors, medical
equipment and consumables, along with other contaminated items.
2. TYPES OF COVID-DEDICATED FACILITIES
During community transmission, multiple COVID-19 treatment areas may be necessary. Based on WHO1
guidelines and experience of countries such as China and India2, a hub and spoke model is recommended where
different levels of care can be provided to patients based on the severity of symptoms.
Table 1: COVID-dedicated facilities
Level 1
Hospitals
Level 2
Primary health centres
Level 3
COVID care centres
Symptom severity Severe Moderate Mild, asymptomatic
Infrastructure Full hospital or a separate
hospital block, preferably
with a separate entry and
exit
Full hospital or a separate
hospital block, preferably
with a separate entry and
exit
Hostels, hotels, schools,
stadiums, lodges, etc.
(existing quarantine
facilities, if required)
Facilities Fully equipped ICUs,
ventilators and beds with
assured oxygen support
Beds with assured oxygen
support
Individual rooms for
suspect cases where
possible
• All centres must have separate areas for suspect and confirmed COVID cases. Suspect and confirmed cases
should not be allowed to mix under any circumstances.
• Level 3 centres must be mapped to one or more primary health centres and at least one hospital.
• Level 2 centres must be mapped to at least one hospital.
• Level 2 and 3 centres must have a dedicated basic life support (BLS) ambulance equipped with sufficient
oxygen support to ensure safe transport of a case to a higher level care center should symptoms worsen.
3. SPACE ROUTING IN COVID FACILITIES
These guidelines, published by the Jack Ma Foundation3 and CDCP4, should be adopted to the maximum possible
extent:
• Hospitals should be strictly divided into contaminated zones, semi-contaminated zones and clean zones. An
operation workflow chart should be clearly explained to all medical staff involved. There should be a buffer
room between different areas:
o Clean zone functions: shower, hand-washing, toilet, office work, expert discussion, resting for
person on duty, changing clothes, donning protective equipment, etc.
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o Semi-contaminated zone functions: a buffer area for staff moving from contaminated areas to
sterile areas with functions including hand-washing, removing PPE, storing medical wastes and
recycles, washing and disinfection supplies.
o Contaminated zone functions: patient diagnostic and examination areas, concentrated medical
consultation rooms, sample collection rooms, imaging examination rooms, laboratories, and
pharmacies. These areas should be installed with negative pressure equipment or an air
disinfection machine.
• Medical staff passages and patients’ passages should be separately designed. Moreover, clean passages and
contaminant passages should be strictly separated to avoid any unnecessary interaction between medical
staff and patients. If feasible, the entrance and exit of the medical staff passage should be located at the
end of the clean zone, with the entrance and exit of the patient passage located at the end of the
contaminated zone.
Figure 1: Illustration of zones3
• There should be unidirectional flow of staff, patients, medical consumables, and contaminated items.
• An independent passage should be designed for contaminated items. Also, a visual region should be set up
for one-way delivery of items from an office area (potentially contaminated zone) to an isolation ward
(contaminated zone).
• Dedicated areas should be earmarked for donning and doffing of essential PPE:
o There should be a separate earmarked donning area at staff entry
o There should be a separate doffing area at exits from wards, outpatient departments, etc.
o Donning and doffing areas should have a hand-washing facility with soap/sanitiser available at all
times.
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4. MECHANICAL, ELECTRICAL AND PLUMBING (MEP) MODIFICATIONS
4.1. HEATING, VENTILATION, AIR CONDITIONING (HVAC): AREAS WITH INFECTED PATIENTS
INCLUDING TRIAGE, RADIOLOGY
Negative isolation requirements5:
• Minimum of 12 air changes per hour.
• The negative pressure should exceed the supply by about 30%.
• The bathroom/WC should be at negative pressure to the isolation room (cubic feet per minute (CFM)
between the two rooms).
• The exhaust from the isolation rooms should be at least 25ft from other ventilation intakes or occupied
areas.
• Ventilation switching controls should NOT be within reach of patients, visitors or members of the public.
Controls should either be key-operated (with the key available along with drug cupboard keys) or switches
should be held outside from the ward.
• Temperature controls should be within the room, so there is no temptation to open doors or windows
whatever the season
• Exhaust ducts should be oversized to allow for loss of efficiency (i.e. expected air flow plus 50%). Exhaust
ducts should be labelled "Caution - negative pressure isolation room exhaust". Labels should be present at
least every 20ft along the ducting and at all penetration points.
• The fan discharge should be directed vertically upward at a speed of at least 2,000ft per min (FPM). The
discharge location should be at least 25ft away from public areas or openings into buildings.
• Permanent room pressure monitors provide instant notification if pressurisation fails or fluctuates.
Monitors must accurately and reliably measure a negative pressure of -0.001 WC.
• An alarm should sound when room pressurisation drifts to less than the monitor reference pressure value
and be programmable for a built-in time delay. The audible alarm should stop when 'mute' button is pressed
and when negative pressure is restored. The visual alarm is a red warning light (also, ‘green’ or ‘safe’ light).
Remote alarm based at nurses’ station.
EXPERIENCE FROM INDIA
To ensure a separate and single point of entry and exit for isolation areas:
o Most hospitals have a separate entry and exit for emergency areas. Given a lack of multiple
entrances and exits in the main hospital building, emergency rooms (ERs) have been converted into
COVID isolation wards, with all necessary equipment.
o Hospitals with multiple buildings have converted one of the smaller buildings into specific isolation
areas.
Some hospitals not yet designated to treat COVID-19 patients have designed passages for unidirectional
movement of critical patients to the ICU, followed by immediate disinfection of the passage.
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• Negative pressure value should be at least 0.006 WC.
4.2. HVAC: ISOLATION WARDS
Table 2: HVAC controls and requirements5
Control
measure
Requirements
Outdoor air
ventilation
Dilutes indoor viral and bacterial contamination. Refer to ASHRAE 170 for details.
Filtration Adding highly-efficient particle filtration (HEPA and/or ULPA) to central ventilation
systems reduces the airborne load of infectious particles proposed in exhaust units.
Pressure
differential
Wards kept at negative pressure to the surrounding areas help keep potential infectious
agents within the rooms.
As per ASHRAE/ASHE Standard 170-2017: Ventilation of Health Care Facilities, the
pressure difference required to maintain negative pressure is minimum 2.5 Pa.
Anterooms Isolation anterooms with appropriate ventilation/pressure relationships prevent the
spread of airborne contaminants from space to space.
When an anteroom is provided, the pressure relationships shall be as follows:
(1) AII rooms should be at a negative pressure to the anteroom, and
(2) the anteroom should be at a negative pressure to the corridor
Temperature
and relative
humidity (RH)
These conditions can inhibit or promote the growth of bacteria, and activate or
deactivate viruses. Statistical analysis suggests RH has a greater effect on viral
inactivation than temperature. Also, viral inactivation appears to be more rapid at 50%
RH than at 20% or 80% RH.
Increasing air
changes
Patients can be isolated in individual isolation rooms or negative pressure rooms with 12
or more air-changes per hour.
Ultraviolet
light, ionisation
and chemicals
A disinfection method used to kill inactivate micro-organisms by disrupting their DNA,
leaving them unable to perform vital cellular functions.
EXPERIENCE FROM INDIA
To convert the isolation/ICU area for suspect patients into a negative pressure area, some hospitals in
India have disconnected the isolation area from the central air conditioning and air handling unit (AHU)
and have installed split air conditioners in the isolation ward.
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Outdoor air
intakes
Air intakes should be located at least 9m from any Class 4 air exhaust discharges as
defined in Standard 62.1-2010.
Exhaust air
outlets
Should be located a minimum of 3m above ground level and away from doors, occupied
areas, and operable windows. Preferred location for exhaust outlets is at roof level
projecting upward or horizontally away from outdoor air intakes.
4.3. HVAC: OTHER AREAS
For non-negative air pressure rooms:
• Ensure adequate room ventilation.
• If room is air-conditioned, ensure 12 air changes per hour and filtering of exhaust air.
5. VISITOR RESTRICTION POLICY
To protect staff, patients, and the community during the COVID-19 outbreak, routine visiting should be
suspended in all multi-specialty hospitals until the transmission of COVID-19 is no longer a threat.*
According to University of Washington, School of Medicine guidelines 6 visitors should be allowed based on the
exception list outlined below. This exception list is only applicable if there is absence of symptoms on screening
the visitor:
• Obstetric patients may have one partner and one birth support person accompany them (no children under
the age of 16).
• Patients under the age of 18 may have one visitor, parent or guardian.
• For the nursery/neonatal ICU, birth parent plus one significant other.
• Patients at the end-of-life may have only two visitors.
• Patients with disruptive behavior, where a family member is key to their care, may have only one visitor.
• Patients who have altered mental status or developmental delays (where caregiver provides safety) may
have only one visitor.
• Patients who require a home caregiver that needs to be trained.
• Patients undergoing surgery or procedures may have one visitor, who should leave the medical centre as
soon as possible after the procedure.
• Patients receiving lodging services as part of their medical treatment plan are excluded from the visitor
restriction policy.
• Patients visiting the emergency department may have one person with them.
* The policy incorporates guidelines issued by the University of Washington School of Medicine and CDCP. Before adoption, it should be modified in accordance with guidelines issued by local governments.
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• The restrictive policy includes employees that have family members who are in the hospital. Any exceptions
to this must be cleared by the clinical administrator.
Based on by CDCP guidelines, procedures for monitoring and managing allowed visitors should include the
following:4, 7
• Points of entry to the facility should be limited.
• All visitors should perform hand hygiene before entering the facility. Alcohol-based hand rub should be
available at every entry point.
• All visitors should be assessed for fever and respiratory symptoms upon entry. If fever or respiratory
symptoms are present, visitor should not be allowed entry.
• Thresholds should determine where visitor screening will be initiated, and the point where screening will
escalate from passive to active to restricting all visitors to the facility.
• While in the facility – and especially in common areas – all visitors should perform frequent hand hygiene
with alcohol-based hand rub and follow respiratory hygiene and cough etiquette precautions.
• Visual alerts (signs, posters) should be placed at the entrance and in strategic places (waiting areas,
elevators) advising visitors not to enter the facility when ill.
• Visitors should be informed about appropriate PPE use according to facility policy.
• Movement of visitors in the facility should be limited (e.g. avoiding the cafeteria) and they should be
instructed to avoid touching high-surface areas.
• Visitors to the most vulnerable patients (e.g., oncology and transplant wards) should be screened for
symptoms before entering the unit.
• A record (e.g., a log with complete and correct contact information so they may be contactable if needed)
of all visitors who enter and exit the COVID rooms should be maintained.
• Visits should be scheduled and controlled to allow for the following:
o Facilities should evaluate risk to the health of the visitor (e.g., visitor might have underlying illness
putting them at higher risk for COVID-19) and ability to comply with precautions.
o Facilities should provide instruction, before visitors enter patients’ rooms, on hand hygiene,
limiting surfaces touched, and use of PPE while in the patient’s room.
o Visitors should not be present during specimen collection procedures.
• The hospital should have a process to allow for remote communication between patient and visitor (e.g.,
video-call applications on cell phones or tablets) and policies addressing when visitor restrictions will be
lifted.
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Standard Operating Protocols: COVID-19
Clinical and non-clinical SOPs
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This section includes guidelines for patient management and infection control and prevention within hospitals.
It is intended to help design protocols for triage, admission, diagnosis, discharge, and death of suspected and
confirmed COVID-19 patients. This section also covers PPE usage and proper and timely environment cleaning
and disinfection.
6. PATIENT FLOW MANAGEMENT
6.1. OUTPATIENT MANAGEMENT
To minimise exposures to respiratory pathogens, hospital policies and practices should ensure measures are
implemented before patient arrival, upon arrival, throughout the patient’s visit, and until the patient’s room is
cleaned and disinfected.4
• Before arrival:
o When scheduling routine medical appointments, instruct patients to call ahead and discuss the
need to reschedule the appointment if they develop symptoms of a respiratory infection (e.g.,
cough, sore throat, fever) on the day they are scheduled to be seen.
o When scheduling appointments for patients requesting evaluation for a respiratory infection, use
nurse-directed triage protocols to determine if an appointment is necessary or if the patient can
be managed from home.
▪ If the patient must come in for an appointment, instruct them to call beforehand to inform
triage personnel they have symptoms of a respiratory infection and to take appropriate
preventive actions (e.g., follow triage procedures, wear a facemask upon entry and
throughout their visit or, if a facemask cannot be tolerated, use a tissue to contain
respiratory secretions).
▪ If a patient is arriving via emergency medical services (EMS) transport, EMS personnel
should contact the receiving ED or healthcare facility and follow previously agreed upon
local or regional transport protocols. This will help the healthcare facility prepare to
receive the patient.
• Upon arrival and during the visit:
o Consider limiting points of entry to the facility.
o Take steps to ensure all persons with symptoms of COVID-19 or other respiratory infection follow
respiratory hygiene and cough etiquette, hand hygiene, and triage procedures throughout the
duration of the visit:
▪ Post visual alerts (signs, posters) at the entrance and in strategic places (waiting areas,
elevators, cafeterias) to provide patients and HCPs with instructions (in appropriate
languages) about hand hygiene, respiratory hygiene and cough etiquette. Instructions
should include how to use tissues to cover both nose and mouth when coughing or
sneezing, to dispose of tissues and contaminated items in waste receptacles, and how and
when to perform hand hygiene.
▪ Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based
hand rub (ABHR) with 60-95% alcohol, tissues, and no-touch receptacles for disposal, at
healthcare facility entrances, waiting rooms, and patient check-ins.
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▪ Install physical barriers (glass or plastic windows) at reception areas to limit close contact
between triage personnel and potentially infectious patients.
▪ Consider establishing triage stations outside the facility to screen patients before they
enter.
o Ensure rapid safe triage and isolation of patients with symptoms of suspected COVID-19 or other
respiratory infection (e.g., fever, cough):
▪ Prioritise triage of patients with respiratory symptoms
▪ Triage personnel should issue a supply of facemasks and tissues to patients with
symptoms of respiratory infection at check-in. Source control (putting a facemask over
the mouth and nose of a symptomatic patient) can help to prevent transmission.
▪ Ensure that, at the time of patient check-in, all patients are asked about the presence of
symptoms of a respiratory infection, contact with possible COVID-19 patients and history
of travel to areas experiencing COVID-19 transmission.
▪ Patient documents should be handled carefully, as they can easily carry and spread
infection. As far as possible, e-documents should be used to avoid any transmission.
▪ Isolate the patient in an examination room with the door closed. If an examination room
is not readily available, ensure the patient is not allowed to wait among other patients
seeking care.
• Identify a separate, well-ventilated space that allows waiting patients to be
separated by a distance of at least 6ft, with easy access to respiratory hygiene
supplies.
• In some settings, patients might opt to wait in a personal vehicle or outside the
healthcare facility where they can be contacted by mobile phone when it is their
turn to be evaluated.
o Include questions about new onset of respiratory symptoms into daily assessments of all admitted
patients. Monitor for and evaluate all new fevers and respiratory illnesses among patients. Place
any patient with unexplained fever or respiratory symptoms on appropriate transmission-based
precautions and evaluate.
EXPERIENCE FROM INDIA
Most hospitals have set-up triage areas outside the hospital or at hospital entry points. As well as
noting patient history and symptoms, hospitals are also scanning visitor temperatures (Infrared
thermal scanner) and vitals (Finger Spo2 monitor).
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6.2. TRIAGE – FOR EARLY RECOGNITION OF PATIENTS WITH COVID-19
The purpose of triage is to recognise and sort all patients with COVID-19 at the first point of contact with the
healthcare system (such as the emergency department). COVID-19 is to be considered a possible etiology† under
certain conditions mentioned in the below table
Table 3: WHO definition of patients8
Suspected • A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath), AND a history of travel to, or residence in, a location reporting community transmission of COVID-19 disease during the 14 days prior to symptom onset;
or
• A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to symptom onset;
or
• A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND requiring hospitalisation) AND in the absence of an alternative diagnosis that fully explains the clinical presentation.
Probable • A suspect case for whom testing for the COVID-19 virus is inconclusive of the result of the test reported by the laboratory;
or
• A suspect case for whom testing could not be performed for any reason.
Confirmed • A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.
† Etiology is the cause or set of causes of a disease or an abnormal condition.
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6.3. ADMISSION CRITERIA
Figure 5: Admission criteria for symptomatic patients
• Patients with mild disease do not require hospital interventions‡; but isolation is necessary to contain virus
transmission. Though most patients with mild disease may not have indications for hospitalisation, there is
a need to contain and mitigate transmission. This can be done either in hospital, if there are just sporadic
cases or small clusters, in repurposed, non-traditional settings; or at home.
• Patients with mild COVID-19 should be provided with symptomatic treatment such as antipyretics for fever.
• Patients with mild COVID-19 should be counselled about signs and symptoms of complicated disease, and
should seek urgent care if they develop any of these symptoms.
• Possible risk factors for progressing to severe illness may include, but are not limited to, older age, and
underlying chronic medical conditions such as lung disease, cancer, heart failure, cerebrovascular disease,
renal disease, liver disease, diabetes, immunocompromising conditions, and pregnancy.
The decision to monitor a patient in the inpatient or outpatient setting should be made on a case-by-case basis.
This decision will depend not only on the clinical presentation, but also on the patient’s ability to engage in
monitoring, home isolation, and the risk of transmission in the patient’s home environment.9
‡ As a precautionary measure, patients with mild illness should also be hospitalised, subject to available bed capacity.
Symptom check
Does the patient have any of the following symptoms:
• Fever ≥100 F or 37.8C
• New cough
• New shortness of breath
No
Proceed as routine visit
Yes
Mild illness
Self-quarantine/ isolation
Moderate illness
Isolation ward
Severe illness
Critical care
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6.4. DIAGNOSIS
According to the Ministry of Health and Family Welfare, India10, the following diagnosis guidelines should be
considered during diagnosis of COVID-19:§
• General guidelines
o Trained healthcare professionals should wear appropriate PPE with latex-free purple nitrile gloves
while collecting the sample from the patient. Maintain proper infection control when collecting the
specimen.
o Restrict entry to visitors or attendants during sample collection
o Complete the requisition form for each specimen submitted
o Ensure proper disposal of all waste generated
• Guidelines for specimen type:
o Preferred sample: throat and nasal swab in viral transport media (VTM) and transported on ice
o Alternate: nasopharyngeal swab, BAL or endotracheal aspirate, which has to be mixed with the
viral transport medium and transported on ice.
• Sample collection and testing guidelines:
o Lower respiratory tract
▪ Bronchoalveolar lavage, tracheal aspirate, sputum.
▪ Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry
container.
o Upper respiratory tract
▪ Oropharyngeal swab (e.g. throat swab):
• Tilt patient’s head back 70 degrees. Rub swab over both tonsillar pillars and
posterior oropharynx and avoid touching the tongue, teeth, and gums. Use only
synthetic fiberswabs with plastic shafts (do not use calcium alginate swabs or
swabs with wooden shafts). Place swabs immediately into sterile tubes
containing 2-3 ml of viral transport media.
▪ Combined nasal and throat swab:
• Tilt patient’s head back 70 degrees. While gently rotating the swab, insert swab
less than one inch into nostril (until resistance is met at turbinates). Rotate the
swab several times against nasal wall and repeat in other nostril using the same
swab. Place tip of the swab into sterile viral transport media tube and cut off the
applicator stick. For throat swab, take a second dry polyester swab, insert into
mouth, and swab the posterior pharynx and tonsillar areas (avoid the tongue).
Place tip of swab into the same tube and cut off the applicator tip.
▪ Nasopharyngeal swab:
§ The policy incorporates guidelines issued by the Government of India. Before adoption, it should be modified in accordance with guidelines issued by local governments.
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• Tilt patient’s head back 70 degrees. Insert flexible swab through the nares
parallel to the palate (not upwards) until resistance is encountered or the
distance is equivalent to that from the ear to the nostril of the patient. Gently,
rub and roll the swab. Leave the swab in place for several seconds to absorb
secretions before removing.
▪ Clinicians may also collect lower respiratory tract samples when these are readily available
(for example, in mechanically ventilated patients). In hospitalised patients with confirmed
COVID-19 infections, repeat upper respiratory tract samples should be collected to
demonstrate viral clearance.
6.5. INPATIENT MANAGEMENT
Based on CDCP guidelines4 ,11, the following asepsis protocols are recommended in inpatient wards:
• If admitted, place a confirmed COVID-19 patient in isolation ward or critical care depending on severity.
• A patient with suspected COVID-19 should be placed in a single-person room with the door closed. The
patient should have a dedicated bathroom to reduce the risk of transmission.
• The following patients should remain in airborne precautions:
o Suspected or confirmed patients who require ICU-level care.
o Patients who require aerosol-generating procedures (using metred dose inhalers instead of
nebulisers for persons being tested for or diagnosed with COVID-19 is strongly recommended).
o Negative pressure airborne isolation rooms should be used, if available. If negative pressure rooms
are unavailable, patients should be placed in a standard room with staff using N95 respirators with
eye protection/PAPRs, gowns and gloves.
• To limit HCPs exposure and conserve PPE, facilities should consider designating entire units within the
facility, with dedicated HCPs assigned to care only for those known or suspected COVID-19 patients during
their shift.
o Determine how staffing needs will be met as the number of patients with known or suspected
COVID-19 increases and HCPs become ill and are excluded from work.
o It might not be possible to distinguish patients diagnosed with COVID-19 from patients with other
respiratory viruses. As such, patients with different respiratory pathogens will likely be housed on
the same unit. However, only patients with the same respiratory pathogen may be housed in the
same room.
o HCPs that enter the room of a patient with known or suspected COVID-19 should follow standard
precautions and use a respirator or facemask, gown, gloves, and eye protection. When available,
respirators (instead of facemasks) are preferred; they should be prioritised for situations where
respiratory protection is most important and the care of patients with pathogens requiring
airborne precautions (e.g., tuberculosis, measles, and varicella).
o All PPE protocols related to donning, doffing, sterilisation and the disinfection process should be
practiced. HCPs should also practice protocols to ration the use of PPE.
• Limit transport and movement of the patient outside of the room to medically essential purposes.
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o Consider providing portable x-ray equipment in patient cohort areas to reduce the need for patient
transport.
• Where possible, patients with known or suspected COVID-19 should be housed in the same room for the
duration of their stay in the facility (e.g., minimise room transfers).
• Patients should wear a facemask during transport to contain secretions. If patients cannot tolerate a
facemask or one is not available, they should use tissues to cover their mouth and nose.
• Once the patient has been discharged or transferred, HCPs (including environmental services personnel)
should not enter the vacated room until sufficient time has elapsed for enough air changes to remove
potentially infectious particles. After this time has elapsed, the room should undergo appropriate cleaning
and surface disinfection before it is returned to routine use.
• Precautions while performing aerosol-generating procedures:
o Some procedures performed on patients may be more likely to generate higher concentrations of
infectious respiratory aerosols than coughing, sneezing, talking, or breathing. These procedures
potentially put HCPs and others at an increased risk for COVID-19 exposure. Although not
quantified, procedures posing higher risk include: cough-generating procedures, bronchoscopy,
sputum induction, intubation and extubation, cardiopulmonary resuscitation, and open suctioning
of airways.
o Ideally, a combination of measures should be used to reduce exposures from these aerosol-
generating procedures when performed on patients with suspected or confirmed COVID-19.
Precautions for aerosol-generating procedures include:
▪ Only performing these procedures if they are medically necessary and cannot be
postponed.
▪ Limiting the number of HCPs present during the procedure to those essential for patient
care and support.
▪ Conducting procedures in an airborne infection isolation room (AIIR) when feasible. Such
rooms are designed to reduce the concentration of infectious aerosols and use controlled
air exchanges and directional airflow to prevent their escape into adjacent areas.
▪ HCPs should follow standard airborne precautions and wear gloves, a gown, either a face
shield that fully covers the front and sides of the face or goggles, and respiratory
protection (at least as protective as an N95 filtering respirator) during aerosol-generating
procedures.
▪ Unprotected HCPs should not be allowed in a room where an aerosol-generating
procedure has been conducted until sufficient time has elapsed to remove potentially
infectious particles.
6.6. DISCHARGE AND FOLLOW-UP
COVID-19 patients may be discharged from hospital and moved to home care (or other types of non-hospital
care and isolation) based on the following guidelines issued by ECDC:12
• In the early stages of SARS-CoV-2 spread (limited number of cases and no apparent sustained transmission):
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o Clinical criteria (e.g. no fever for more than three days, improved respiratory symptoms, pulmonary
imaging showing obvious absorption of inflammation, no hospital care needed for other pathology,
clinician assessment);
o Laboratory evidence of SARS-CoV-2 clearance in respiratory samples; two to four negative RT-PCR tests
for respiratory tract samples (nasopharynx and throat swabs with sampling interval ≥ 24 hours). Testing
at a minimum of seven days after the first positive RT-PCR test is recommended for patients that
clinically improve earlier.
• In the context of sustained widespread transmission, alternative algorithms for hospital discharge of COVID-
19 patients are warranted:
o The discharge from hospital of mild cases – if clinically appropriate – may be considered, provided they
are placed into home care or another type of community care.
o After discharge, 14 days of further isolation with regular health monitoring (e.g. follow-up visits, phone
calls) can be considered, provided the patient’s home is equipped for patient isolation and the patient
takes all necessary precautions (e.g. single room with good ventilation, facemask wear, reduced close
contact with family members, separate meals, good hand sanitation, no outdoor activities) in order to
protect family members and the community from infection and further spread of SARS-CoV-2.
6.7. PROTOCOLS AFTER DEATH
There is no evidence established so far that transmission of COVID-19 can take place through the handling of
bodies of deceased persons. According to a WHO report, the lungs of dead COVID patients, if handled during an
autopsy, can be infectious.13
The following WHO-based guidelines13 should be followed for safe management of dead bodies during the
spread of COVID-19:
PREPARING AND PACKING THE BODY FOR TRANSFER FROM A PATIENT ROOM TO AN AUTOPSY
UNIT, MORTUARY, CREMATORIUM, OR BURIAL SITE:
• Ensure that personnel who interact with the body (healthcare or mortuary staff, or the burial team) apply
standard precautions, including hand hygiene before and after interaction with the body and the
environment. Personnel should use appropriate PPE according to the level of interaction with the body,
including a gown and gloves. If there is a risk of splashes from body fluids or secretions, personnel should
use facial protection, including a face shield or goggles and medical mask;
• Prepare the body for transfer including removal of all lines, catheters and other tubes;
• Ensure any body fluids leaking from orifices are contained;
• Keep both the movement and handling of the body to a minimum;
• Wrap the body in cloth and transfer it as soon as possible to the mortuary area;
o There is no need to disinfect the body before transfer to the mortuary area;
o Body bags are not necessary, although may be used for other reasons (e.g. excessive body fluid
leakage);
• No special transport equipment or vehicle is required.
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FUNERAL HOME/ MORTUARY CARE:
• Healthcare workers or mortuary staff preparing the body (e.g. washing the body, tidying hair, trimming
nails, or shaving) should wear appropriate PPE according to standard precautions (gloves, impermeable
disposable gown [or disposable gown with impermeable apron], medical mask and eye protection);
• If the family wishes only to view the body and not touch it, they may do so, using standard precautions at
all times including hand hygiene. Give the family clear instructions not to touch or kiss the body;
• Embalming is not recommended to avoid excessive manipulation of the body;
• Adults aged 60 or over and immunosuppressed persons should not directly interact with the body.
AUTOPSY, INCLUDING ENGINEERING AND EN VIRONMENTAL CONTROLS:
• Safety procedures for deceased persons infected with COVID-19 should be consistent with those used for
any autopsies of people who have died from an acute respiratory illness. If a person died during the
infectious period of COVID-19, the lungs and other organs may still contain live virus, and additional
respiratory protection is needed during aerosol-generating procedures (e.g. procedures that generate
small-particle aerosols, such as the use of power saws or washing of intestines);
• If a body with suspected or confirmed COVID-19 is selected for autopsy, healthcare facilities must ensure
safety measures are in place to protect those performing the autopsy;
• Autopsies must be performed in an adequately ventilated room (i.e. at least natural ventilation with at least
160L/s/patient air flow or negative pressure rooms with at least 12 air changes per hour (ACH) and
controlled direction of air flow when using mechanical ventilation);
• The number of staff involved in the autopsy should be kept to a minimum;
• Appropriate PPE must be available, including a scrub suit, long sleeved fluid-resistant gown, gloves (either
two pairs or one pair of autopsy gloves), and face shield (preferably) or goggles, and boots. A particulate
respirator (N95 mask or FFP2 or FFP3 or its equivalent) should be used in the case of aerosol-generating
procedures.
ENVIRONMENTAL CLEANING AND CONTROL
• The mortuary must be kept clean and properly ventilated at all times;
• Lighting must be adequate. Surfaces and instruments should be made of materials that can be easily
disinfected and maintained between autopsies;
• Instruments used during the autopsy should be cleaned and disinfected immediately after the autopsy, as
part of the routine procedure;
• Surfaces where the body was prepared should first be cleaned with soap and water, or a commercially
prepared detergent solution;
• After cleaning, a disinfectant with a minimum concentration of 0.1% (1000 ppm) sodium hypochlorite
(bleach), or 70% ethanol should be placed on the surface for at least one minute. Hospital-grade
disinfectants may also be used as long as they have a label claim against emerging viruses and they remain
on the surface according to manufacturer’s recommendations;
• Personnel should use appropriate PPE, including respiratory and eye protection, when preparing and using
the disinfecting solutions; and
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• Items classified as clinical waste must be handled and disposed of properly according to legal requirements.
7. INFECTION PREVENTION AND CONTROL
These Infection Prevention and Control (IPC) strategies are based on WHO guidelines14,15 to prevent and limit
COVID-19 transmission:
• Ensure triage, early recognition, and source control (isolating suspected and confirmed COVID-19 patients).
• Apply standard precautions for all patients, including diligent hand hygiene.
• Implement empiric additional precautions (droplet and contact and, wherever applicable, for aerosol-
generating procedures and support treatments, airborne precautions) for suspected and confirmed cases
of COVID-19.
• Implement administrative controls (such as appropriate infrastructure), develop clear policies, facilitate
access to laboratory testing, appropriate triage and placement of patients (including separate waiting
areas/rooms dedicated to patients with respiratory symptoms) ensure adequate staff-to-patient ratios and
conduct appropriate staff training.
• Use environmental and engineering controls, include providing adequate space to allow social distance of
at least one metre maintained between patients and health care workers, and ensure the availability of
well-ventilated isolation rooms for patients with suspected or confirmed COVID-19, as well as adequate
environmental cleaning and disinfection.
7.1. STANDARD PRECAUTIONS
Standard precautions include15:
• Maintaining physical distancing (a minimum of one metre from other individuals)
• Hand and respiratory hygiene (detailed below)
• Use of appropriate PPE (refer to Section 8.1 for detailed guidelines)
• Injection safety practices
• Safe waste management
• Proper linens
• Environmental cleaning (refer to Section 9 for detailed guidelines)
• Sterilisation of patient care equipment
HCPs should follow the below guidelines for self-monitoring15:
• Self-monitor for symptoms; perform temperature check twice daily and assess for COVID-19-like illness.
• Do not report to work in case of any symptoms of a COVID-19-like illness (including fever, dry cough,
shortness of breath).
• If any signs or symptoms occur while working, immediately leave the patient care area, inform the
supervisor per facility protocol, and isolate from other people.
• Use PPE to minimise the risk of transmission.
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HAND HYGIENE
• Hand hygiene is the most important measure for the prevention and control of COVID-19. Hand hygiene can
be performed with soap and water or alcohol-based hand rubs.
• Duration: hand rub for 20 seconds and hand wash for 40 seconds.
Table 4: Five instances of hand hygiene and examples of clinical situations (Jawaharlal Institute of
Postgraduate Medical Education and Research, India)16
Instance 1 and 4:
Before and after touching a patient
Instance 2 and 3:
Before and after aseptic procedure/body fluid exposure
Instance 5:
After touching patient surroundings
Before and after:
• Taking pulse or blood pressure
• Auscultation and palpation
• Shaking hands
• Helping a patient move around
• Applying oxygen mask
• Giving physiotherapy
• Recording ECG
• Use of gloves
Before and after:
• Oral or dental care
• Aspiration of secretions or accessing draining system
• Skin lesion care or wound dressing
• Giving injection
• Drawing of blood or sterile fluid
• Handling an invasive device (catheter, central line, ET tube)
• Clearing up urines, feces, vomit
• Handling bandages or napkins
• Instilling eye drops
• Moving from a contaminated body site to another body site during care of the same patient
After contact with:
• Handling the case sheet
• Medical equipment in the immediate vicinity of the patient
• Bed or bed rail
• Changing bed linen
• Decanting uro-bag
RESPIRATORY HYGIENE AND COUGH ETIQUETTE
Table 5: Respiratory hygiene dos and don'ts (Jawaharlal Institute of Postgraduate Medical Education and
Research, India)16
DOs DON'Ts
• Cough or sneeze with a tissue paper or into your sleeve if no tissue is available
• Perform hand hygiene after coughing or sneezing onto hands
• Don’t cough or sneeze on your hands. Perform hand hygiene after coughing or sneezing onto hands
• Turn head away from others when coughing or sneezing
• Don’t cough or sneeze near other people
• Don’t spit
• If tissues are used, discard into yellow bag • Don’t discard tissues into other BMW bags
Maintain one metre (two-arm) distance
• If you have cough or are sneezing
• From people with respiratory symptoms
Don’t stay within one metre from others
• If you have a cough or are sneezing
• From people with respiratory symptoms
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• Including contacts of coronavirus cases in quarantine
• Including contacts of coronavirus cases in quarantine
7.2. EMPIRIC ADDITIONAL PRECAUTIONS
CONTACT AND DROPLET PRECAUTIONS
Along with standard precautions, all individuals – including family members, visitors and HCPs – should use
contact and droplet precautions before entering the room of suspected or confirmed COVID-19 patients: 15
• Patients should be placed in adequately ventilated single rooms. For general ward rooms with natural
ventilation, adequate ventilation is considered to be 60 L/s per patient;
• Where single rooms are not available, patients suspected of having COVID-19 should be grouped together;
• All patients’ beds should be placed at least one metre apart, regardless of whether patients are suspected
to have COVID-19;
• Where possible, a team of HCPs should be designated to care exclusively for suspected or confirmed cases
to reduce the risk of transmission;
• HCPs should use appropriate PPE (including mask, eye protection (goggles), facial protection (face shield),
gown, gloves) to reduce transmission risk.
• After patient care, appropriate doffing and disposal of all PPE and hand hygiene should be carried out. A
new set of PPE is needed when care is given to a different patient;
• Equipment should be either single-use or disposable or dedicated equipment (e.g. stethoscopes, blood
pressure cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect it
between use for each individual patient (e.g. by using ethyl alcohol 70%).
• HCPs should avoid touching the eyes, nose, or mouth with potentially contaminated gloved or bare hands;
• Avoid moving and transporting patients out of their room or area unless medically necessary. Use
designated portable x-ray equipment or other designated diagnostic equipment. If transport is required,
use predetermined transport routes to minimise exposure for staff, other patients and visitors, and ensure
the patient wears a medical mask;
• Healthcare workers who are transporting patients should perform hand hygiene and wear appropriate PPE;
• Before the patient’s arrival, notify the area receiving the patient of any necessary precautions;
• Routinely clean and disinfect any surfaces that come into contact with the patient;
• Limit the number of HCPs, family members, and visitors who are in contact with suspected or confirmed
COVID-19 patients;
• Maintain a record of all persons entering a patient’s room, including all staff and visitors.
AIRBORNE PRECAUTIONS FOR AEROSOL -GENERATING PROCEDURES
Some aerosol-generating procedures, such as tracheal intubation, non-invasive ventilation, tracheotomy,
cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy, have been associated
with an increased risk of transmission of coronaviruses. Ensure that healthcare workers performing aerosol-
generating procedures: 15
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• Perform procedures in an adequately ventilated room – that is, natural ventilation with air flow of at least
160 L/s per patient or in negative-pressure rooms with at least 12 air changes per hour and controlled
direction of air flow when using mechanical ventilation;
• Use a particulate respirator at least as protective as a US National Institute for Occupational Safety and
Health (NIOSH)-certified N95, European Union (EU) standard FFP2, or equivalent. When healthcare workers
put on a disposable particulate respirator, they must always perform the seal check.
• Use eye protection (i.e. goggles or a face shield) and wear a gown and gloves. If gowns are not fluid-resistant,
HCPs should use a waterproof apron for procedures expected to create high volumes of fluid that might
penetrate the gown;
• Limit the number of persons present in the room to the absolute minimum required for the patient’s care
and support.
7.3. ADMINISTRATIVE CONTROLS
Administrative controls and policies for prevention and control of transmission of COVID-19 within the health
care setting include, but may not be limited to: 15
• Establishing sustainable IPC infrastructures and activities;
• Educating patients’ caregivers;
• Developing policies on early recognition of acute respiratory infection potentially caused by COVID-19;
• Ensuring access to prompt laboratory testing for identification of the etiologic agent;
• Preventing overcrowding, especially in emergency departments;
• Providing dedicated waiting areas for symptomatic patients;
• Appropriately isolating hospitalised patients;
• Ensuring adequate supplies of PPE; and
• Ensuring observance of IPC policies and procedures for all aspects of healthcare.
MEASURES RELATED TO HCPS
• Provision of adequate training for HCPs;
• Ensuring an adequate patient-to-staff ratio;
• Establishing a surveillance process for respiratory infections caused by COVID-19 among HCPs;
• Ensuring HCPs and the public understand the importance of promptly seeking medical care;
• Monitoring HCP compliance with standard precautions and providing mechanisms for improvement as
needed.
7.4. ENVIRONMENT AND ENGINEERING CONTROLS
• These controls address the basic infrastructure of the healthcare facility and aim to ensure adequate
ventilation in all areas, as well as adequate environmental cleaning.
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• Additionally, separation of at least one metre should be maintained between all patients. Both spatial
separation and adequate ventilation can help reduce the spread of many pathogens in the healthcare
setting.
• Ensure cleaning and disinfection procedures (detailed in Section 9) are followed:
o Cleaning environmental surfaces with water and detergent and applying commonly used hospital
disinfectants (such as sodium hypochlorite) is effective and sufficient.
o Manage laundry, food service utensils and medical waste by following safe routine procedures.15
7.5. PROCEDURE FOR REMEDIAL ACTIONS AGAINST OCCUPATIONAL EXPOSURE TO COVID-19
Remedial actions to be undertaken in case any staff member gets exposed in any manner (Zhejiang University
School of Medicine):17
Figure 2: Occupational exposure
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8. PERSONAL PROTECTIVE EQUIPMENT (PPE)
8.1. PPE COMPONENTS
PPE comprises goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), head cover and shoe
cover.18 Hospitals should ensure all PPE equipment is fit for purpose and suits the different body types of male
and female healthcare personnel. Wherever possible, processes and procedures adopted during the COVID-19
emergency should be incorporated into occupational health and safety systems that hospitals have already
developed.
Table 6: PPE usage
PPE Description
Face-shield and goggles
• Protecting mucous membranes of the eyes, nose and mouth through face-shields/ goggles is an integral part of standard and contact precautions.**
• Contamination of mucous membranes is likely in a scenario of droplets generated by coughs or sneezes of an infected person, or during aerosol-generating procedures carried out in a clinical setting.
• Another likely scenario for infection is through inadvertently touching the eyes, nose and mouth with a contaminated hand.
Masks:
Triple-layer medical mask
N-95 respirator mask
• Respiratory viruses (including Coronavirus) target mainly the upper and lower respiratory tracts. Therefore, protecting the airway from the particulate matter generated by droplets or aerosols prevents human infection.
• Different types of mask should be used relative to the specific risk profile of the category of personnel and their work. Two types of mask are recommended for personnel working in hospital or community settings:
o The triple-layer medical mask is disposable and fluid-resistant. It protects the wearer from droplets of infectious material emitted during coughing, sneezing and talking.
o The N-95 respirator mask is a respiratory protective device with high filtration efficiency to airborne particles. To provide the requisite air seal to the wearer, such masks are designed to achieve a very close facial fit.
Gloves • When a person touches an object or surface contaminated by a COVID-19 infected person, and then touches their own eyes, nose, or mouth, they may be exposed to the virus.
** Standard precautions: use of respirator or face-mask, gown, gloves, and eye protection. Contact and droplet precautions: use of mask and tissues to prevent respiratory droplets from transmission.
31 | P a g e
• Nitrile gloves are preferred over latex gloves because they resist chemicals, including certain disinfectants such as chlorine. Health workers also experience a high rate of latex allergies and contact dermatitis.
Coveralls and gowns
• Coveralls and gowns are designed to protect the torso of healthcare providers from virus exposure.
• Coveralls should also cover the head.
• Healthcare workers working in close proximity (within one metre) of suspect/confirmed COVID-19 cases or their secretions must wear appropriate protective clothing that create a barrier to eliminate or reduce contact and droplet exposure, both known to transmit COVID-19.
Shoe covers
• Shoe covers are designed to protect the feet of healthcare providers and to prevent contamination. Shoe covers should be made up of impermeable fabric, and be worn over shoes.
Head cover
• Healthcare workers wearing gowns should also use a head cover that covers the head and neck while providing clinical care for patients.
• Hair and hair extensions should fit inside the head cover.
8.2. PPE REQUIREMENT
Table 7: Recommended PPE during the COVID-19 outbreak, according to the setting, personnel, and type of
activity (based on WHO guidelines)14
Settings Target personnel or patients
PPE
Respiratory protection
Body protection Eye protection
Surgical mask
N95 mask
Gloves Gowns Goggles or face-shield
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Inpatient facilities
Screening/ clinical triage (preliminary
screening not involving
direct contact)
Healthcare workers
Patients with symptoms suggestive of COVID-19
Patients without symptoms suggestive of COVID-19
Patient room/ ward
Healthcare workers (absence of aerosol- generating procedure)
✓ ✓ ✓ ✓
Healthcare workers (presence of aerosol- generating procedure)
✓ ✓ ✓ ✓
Cleaners ✓ ✓ ✓
Visitors ✓ ✓ ✓
Areas of transit where patients are not allowed
All staff including healthcare workers
Laboratory Lab technician (all work related to specimen handling)
✓ ✓ ✓ ✓
Administrative areas
All staff including healthcare workers
Outpatient facilities
Screening/ triage
Healthcare workers (preliminary screening not involving direct contact)
Patients with symptoms suggestive of COVID-19 ✓
Patients without symptoms suggestive of COVID-19
Waiting room Patients with symptoms suggestive of COVID-19
Patients without symptoms suggestive of COVID-19
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Consultation room
Healthcare workers (physical examination of patient with COVID-19 symptoms)
✓ ✓ ✓ ✓
Healthcare workers (physical examination of patient without COVID-19 symptoms)
✓ ✓ ✓
Patients with symptoms suggestive of COVID-19
Patients without symptoms suggestive of COVID-19
Cleaners ✓ ✓ ✓
Administrative areas
All staff including healthcare workers
8.3. DONNING PPE
Before entering the triage area and isolation room or area:
• Collect all equipment needed.
• Perform hand hygiene with an alcohol-based hand rub (preferably when hands are not visibly soiled) or
soap and water.
• Put on PPE in an order that prevents self-contamination and self-inoculation. For example, start with hand
hygiene, then don gown, shoe covers, mask or respirator, followed by eye protection and finishing with
gloves.
Table 8: Process of Donning PPE19
PPE Description
Hand hygiene • With an alcohol-based hand rub (preferably when hands are not visibly soiled) or soap and water
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Gown/shoe cover • Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back
• Fasten in back of neck and waist
Mask/respirator • Secure ties or elastic bands at middle of head and neck
• Fit flexible band to nose bridge
• Fit snug to face and below chin
• Adjust the respirator to fit
Goggles/face-shield
• Place over face and eyes and adjust to fit
Gloves • Extend to cover wrist of isolation gown
8.4. DOFFING PPE
While leaving the isolation room or area:
• Remove PPE in the anteroom in a manner that prevents self-contamination or self-inoculation with
contaminated PPE or hands. General principles are:
o Remove the most contaminated PPE items first. For example, start with gloves (if the gown is
disposable, peel off gloves and remove together with the gown), follow with hand hygiene, remove
gown, eye protection, mask or respirator and finish with hand hygiene
o Remove the mask or respirator last (by grasping the ties and discarding in a rubbish bin)
o Discard disposable items in a closed rubbish bin
o Put reusable items in a dry (e.g. without any disinfectant solution) closed container
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o Whenever un-gloved hands touch contaminated PPE items perform hand hygiene with
(preferably) an alcohol-based hand rub or soap and water.
Table 21: Process of doffing PPE19
PPE Description
Gloves • Outside of gloves are contaminated
• Using a gloved hand, grasp the palm area of the other gloved hand and peel off first glove
• Hold removed glove in gloved hand
• Slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove
• Discard gloves in a waste container
Goggles/face-shield
• Outside of goggles or face-shield are contaminated
• Remove goggles or face-shield from the back by lifting head band or earpieces
• If the item is reusable, place in designated receptacle for reprocessing. Otherwise, discard in a waste container
Gown • Gown front and sleeves are contaminated
• Unfasten gown ties, taking care sleeves don’t contact your body when reaching for ties
• Pull gown away from neck and shoulders, touching inside of gown only
• Turn gown inside out
• Fold or roll the gown into a bundle and discard in a waste container
Mask/respirator • Front of mask/respirator is contaminated
• Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front
• Discard in a waste container
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Hand hygiene • Wash hands or use an alcohol-based hand sanitiser immediately after removing all PPE
8.5. GUIDELINES FOR LIMITED USE AND CONSERVATION OF PPE
While maintaining the commitment towards excellent patient care and staff, hospitals must take extraordinary
measures to conserve PPE wellbeing, including following the ‘4Rs’ (restrict, reduce, re-use, record) strategy for
PPE conservation:14, 16
Strategy Parameter Description
Restrict Visitors • Surgical masks to be available for visitors with/ without symptoms at the entry point
• Visitors should not be allowed to visit confirmed or probable COVID-19 patients
Restrict contact with patients • Restrict screening area entry to only the HCPs evaluating suspected cases of COVID-19 disease
• In COVID wards: o Limit encounters as much as possible in and
out of the room o Restrict entry to only the attending provider
or primary doctor, donning the necessary PPE for that patient encounter
o Shared visits for attending providers and APP should be limited to just the APP†† to see the patient, unless a clinical consultation is requested for challenging situations
Access to PPEs • Use PPE only if in direct close contact with the patient or when touching the environment
• N95 or respirator masks not be issued outside of COVID-19 assessment units
Reduce Minimise face-to-face encounters • Use telemedicine to evaluate suspected cases of COVID-19
Reducing potential for viral exposure
• Physical controls (like glass or plastic windows) to separate and cohort COVID+ patients
• Isolate suspected patients with proper ventilation systems
• Avoid entering patient rooms for unnecessary care. For example, some systems have started to keep IV pumps outside the patient room by
†† APP- Advanced Practice Providers
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using IV extension tubing to provide access to investigate alarms and change medication
Minimise the need for PPE • Bundle activities involving entering the isolation rooms
• Cohort confirmed COVID-19 patients without coinfection with other transmissible microorganisms in the same room
Eliminating elective surgeries and procedures
• Suspend diagnosis and treatment operations that generate much aerosol
• We recommend suspending routine operations in dentistry (tooth implantation, teeth cleaning and tooth extraction), ENT (rhinoscopy and laryngoscopy), pulmonary function test, endoscopy (bronchoscopy, gastrointestinal endoscopy), breath test (Helicobacter pylori)
• Specialty services should only be provided in an emergency
Reuse PPE
• Wear the same N95 respirator for repeated
close contact encounters with several patients,
without removing the respirator between encounters. Discard when contaminated with blood, respiratory or nasal secretions
• Use the same N95 respirator for multiple encounters with patients but sanitise the respirator after doffing it, using advised disinfectants
Record Coordinate PPE supply chain mechanisms
• Pharmacies should maintain records to keep track of all PPE items
• Each facility/department should control PPE access for their staff and maintain records. PPE usage data from separate facilities can be used to calculate each unit's PPE ‘burn rate’
• Promote a centralised request management approach to avoid stock duplication while maintaining strict stock management rules to limit wastage, overstock, and stock ruptures
• Use PPE forecasts based on rational quantification models that ensure the rationalisation of requested supplies
9. ENVIRONMENTAL CLEANING
The environment cleaning guidelines are based on recommendations of Zhejiang University School of Medicine
China, and Jawaharlal Institute of Postgraduate Medical Education and Research, India. These guidelines should
wherever applicable be adapted according to local government guidelines.
9.1. DISINFECTION OF ISOLATION WARD
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All visible pollutants in an isolation ward should be completely removed before disinfection and handled in
accordance with blood and bodily fluid spills disposal procedures.16, 17
• Disinfection of floors and walls:
o Disinfect floors and walls through floor mopping, spraying or wiping using 1000 mg/L chlorine-
containing disinfectant.
o Perform disinfection procedures three times a day.
• Disinfection of object surfaces:
o Dirty surfaces should be cleaned using a detergent or soap and water before disinfection.
o Wipe object surfaces with 1000 mg/L chlorine-containing disinfectant or wipes with effective
chlorine; wait for 30 minutes and then rinse with clean water.
o Perform disinfection procedures three times a day.
o Wipe cleaner regions first, then more contaminated regions (first wipe the object surfaces that are
not frequently touched, and then wipe those object surfaces that are frequently touched).
• Air disinfection:
o Add HEPA and/or ULPA filtration to central ventilation systems to reduce the airborne load of
infectious particles.
• Disposal of fecal matter and sewage:
o Before being discharged into the municipal drainage system, fecal matter and sewage must be
disinfected by treating with chlorine-containing disinfectant (for the initial treatment, the active
chlorine must be more than 40 mg/L).
o The concentration of total residual chlorine in the disinfected sewage should reach 10 mg/L.
o Ensure the disinfection time is at least 1.5 hours.
• Items/equipment to be used: dust mops, duster, damp cloth and sponge, detergent, sanitiser, hot water,
sodium hypochlorite, alcohol based rub/spirit swab.
• Cleaning agents and disinfectants:
Table 9: Cleaning agents and disinfectants for Isolation rooms and Other Wards:
COVID-19 isolation room
Disinfectant to be used in isolation ward
Disinfectant to be used in other wards
Contact time (mins)
Frequency
High- touch surfaces
Hypochlorite 0.5% (wipe) Bacillocid extra 0.25% (wipe)
10 Twice per shift (4 hourly)
Floor Clean (soap and water) then mop with Hypochlorite 0.5%
Clean (soap and water) then mop with Bacillocid extra 0.25%
10 Once per shift (8 hourly)
Wall, ceiling Hypochlorite 0.5% (wipe) Bacillocid extra 0.25% (wipe)
10 Once daily
Linen (used) Hypochlorite 0.1% Hypochlorite 0.1% 30 As needed
Toilet Clean (soap and water) then wash with Hypochlorite 0.5%
Clean (soap and water) then wash with either Lysol 7%, Hypochlorite 0.5% or Bacillocid extra 0.5%
10 Twice per shift (4 hourly)
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Corridor Hypochlorite 0.5% (wipe) Bacillocid extra 0.25% (wipe)
10 Once per shift (8 hourly)
Non-critical equipment (stethoscope, BP cuff, thermometer etc.)
Alcohol wipes Alcohol wipes - After each use
Slippers Soap and water followed with Hypochlorite 0.1% (dip)
Soap and water followed with Hypochlorite 0.1% (dip)
10 Once per day
Termination disinfection
Soap and water followed with 0.5% hypochlorite
Soap and water followed with Bacillocid extra 0.25%
10 As needed
9.2. DISINFECTION OF HIGH-TOUCH SURFACES
Table 10: Disinfection process of high-touch surfaces in hospitals16
Areas/ Items Agent Process Method/procedure
Stethoscope • Alcohol-based rub or spirit swab
• Cleaning • Wipe with alcohol-based rub or spirit swab before each patient contact
BP cuffs and covers
• Alcohol-based rub or spirit swab
• Detergent and hot water
• Cleaning
• Washing
• Cuffs wiped with alcohol- based disinfectant. Regular laundering is recommended for the cover
Thermometer • Detergent and water
• Alcohol rub
• Individual thermometer holder
• Cleaning • Store dry in individual holder
• Clean with detergent and tepid water
• Wipe with alcohol rub in between patient use
• Store inverted in individual holder
• Preferably one thermometer for each patient
Injection and dressing trolley
• Detergent and water
• Duster
• Disinfectant (70% alcohol)
• Washing
• Cleaning
• Cleaned daily with detergent and water
• Wiped with disinfectant after each use
Mobile phones and landline phones
• Alcohol wipes • Front and back
• Twice per shift
• Before leaving workplace
• Switch off during wiping
Ventilator monitor
Defibrillator
USG machine
• Detergent followed with alcohol (Wettask wipe or Bacilliol-25 spray)
• • Disinfectant will work only when detergent removes the organic matter
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Ventilator tubing • ETO or plasma sterilisation
• Sterilisation • Start with enzymatic cleaning then send for ETO/plasma sterilisation
• Check for type-V chemical
Ventilator-suction apparatus
• Bacillocid extra 1%
• Disinfection • Discard suction fluid as per BMW rule, immerse in detergent, followed by water, then Bacillocid extra for 10-12 min
Lifts/elevators • Bacillocid extra 0.25%
• Cleaning • Clean high-touch lift areas such as buttons, rails and adjacent-wall area, door every hour
• Clean other lift areas every 8 hours
9.3. DISPOSAL OF BLOOD AND BODY FLUID SPILLS
Table 11: Disposal procedure17
Kind of spill Disposal procedure
For small volume spills (< 10 mL)
Option 1: Spills should be covered with disinfecting wipes (containing 5000 mg/L effective chlorine) and carefully removed. Object surfaces should then be wiped twice with chlorine-containing disinfecting wipes.
Option 2: Carefully remove spills with disposable absorbent materials such as gauze, wipes, etc., which have been soaked in 5,000 mg/L chlorine-containing disinfecting solution.
For large volume spills
(> 10 mL)
Option 1: Absorb the spilled fluids for 30 minutes with a clean absorbent towel (containing peroxyacetic acid that can absorb up to one litre of liquid per towel), then clean the contaminated area after removing the pollutants.
Option 2: Completely cover the spill with disinfectant powder or bleach powder containing water-absorbing ingredients, or completely cover it with disposable water-absorbing materials, then pour 10,000 mg/L chlorine-containing disinfectant onto the water-absorbing material (or cover with a dry towel which should be subjected to high-level disinfection).
9.4. DISINFECTION OF REUSABLE MEDICAL EQUIPMENT AND DEVICES
Definition of reusable equipment: powered air purifying respirator, eye protecting equipment, facemasks, and
N95 respirators17
Table 12: Cleaning process
Equipment Process of cleaning
Powered air purifying respirator
Wipe all respirator parts with chlorine-containing disinfectant or a soft cloth dipped in the cleaning liquid. The breathing tube should be soaked in 1,000 mg/L chlorine-containing disinfectant and then washed with clean water. After the parts dry, then must be stored in a zip-lock bag for further use.
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Eye protecting equipment (face shield/goggles)
Carefully wipe the outside of the face shield or goggles using alcohol-based wipes (Clorox wipes) or a clean cloth saturated with chlorine-containing disinfectant solution. Wipe the outside of the face shield or goggles with clean water or alcohol to remove residue.
Facemasks and respirator masks
If there are no visible pollutants, soak it in 5,000 mg/L chlorine-containing disinfectant. Do not reuse if contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients. Do not reuse if the straps are stretched so they no longer provide enough tension for the respirator to seal to the face.
9.5. DISINFECTION OF INFECTIOUS FABRICS
• Infectious fabric includes:
o Clothes, bed sheets, bed covers and pillowcases used by patients.
o Ward area bed curtains.
o Floor towels used for environmental cleaning.
• Collecting infectious fabrics:
o Pack fabrics into a disposable water-soluble plastic bag and seal the bag with matching cable ties.
o Pack this bag into a second plastic bag, seal with cable ties in a gooseneck fashion.
o Finally, pack the plastic bag into a yellow bag (refer to disposal of section 9.6 below) and seal the
bag with cable ties.
o Attach a special infection label and the department name before sending to the laundry room.
• Storage and cleaning of infectious fabric:
o Separate COVID-19 infectious fabrics from other (non-COVID-19) infectious fabrics and wash in a
dedicated washing machine.
o Wash and disinfect these fabrics with 5,000 mg/L chlorine-containing disinfectant at a temperature
of 90 degrees Celsius.17
9.6. DISPOSAL OF BIOMEDICAL WASTE
Guidelines for handling biomedical waste generated in COVID-19 facilities:17, 20
• All waste generated from suspected or confirmed patients should be disposed of as medical waste.
• Put the medical waste into a double-layer medical waste bag, seal the bag with cable ties in a gooseneck
fashion and spray the bag with 1000 mg/L chlorine-containing disinfectant.
• Put sharp objects into a special plastic box, seal the box and spray the box with 1000 mg/L chlorine-
containing disinfectant.
• Put the bagged waste into a medical waste transfer box, attach a special infection label, fully enclose the
box for transfer.
• Transfer the waste to a temporary medical waste storage point along a specified route at a fixed time point
and store the waste separately at a fixed location.
• The medical waste should be collected and disposed of by an approved medical waste disposal provider.
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Standard Operating Protocols: COVID-19
Human resource management
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This section includes guidelines for staffing and training during the COVID-19 outbreak. It is intended to guide
hospitals on rationalising staff to minimise exposure, training clinical and non-clinical staff and preparing
contingency plans for surging patient inflows. This section also includes steps to be taken for the psychological
wellbeing of hospital staff.
10. MINIMISING STAFF EXPOSURE
• Prioritise staffing of ICU and critical care nurses, physicians and nurses specially trained to manage
ventilators and life-supporting medications essential for critically ill patients. Ensure training is given to staff
in other departments who may be call on during staff shortages.
• Outsource services to telehealth centres run by retired healthcare providers and volunteers.
• Designate those surgeons, anaesthesiologists and recovery room nurses with experience of critically ill
patients to care for COVID-19 patients.
• Prepare and implement measures for high-risk staff members (pregnant women, > 60 years, prior medical
ailments, etc.) to ensure their safety.
11. STAFF TRAINING
11.1. TRAINING REQUIREMENTS AND DURATION
In an emergency or disaster, hospital staff are generally required to go beyond their routine day to-day roles
and responsibilities and take on less familiar tasks during what will be, in all probability, a highly stressful
environment. To meet these demands, all staff members – irrespective of their hospital, departmental and
individual duties – need to be involved in the emergency planning process. This will help to distinguish between
routine and emergency responsibilities, so they can make a better contribution to the emergency response. Staff
also need training in implementing risk reduction measures and the procedures and protocols called for in the
Hospital Emergency Response Plan (including the Epidemic Subplan). Staff must, in addition, participate in the
regular drills and exercises needed to maintain a state of readiness for fulfilling planned emergency tasks.
DOCTORS
• Conduct an initial information session and subsequent infection prevention training for all physicians, and
follow all control protocols while on duty, including:
o Regular reporting of symptoms to department as per protocol.
o Re-joining protocols post-sick leave or if kept under isolation.
o Protocols concerning the application of chemoprophylaxis.
• Ensure doctors are trained on the installation and use of PPE consistent with the hospital PPE use protocols
(Section 10).
EXPERIENCE FROM INDIA
Hospitals are following a rostering protocol where HCPs go through 8-14 days quarantine after a two-
week shift (working eight hours per day)
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NURSING
• Conduct an initial information session and subsequent infection prevention training for all nurses, and
follow all control protocols while on duty, including:
o Regular reporting of symptoms to department as per protocol.
o Re-joining protocols post-sick leave or if kept under isolation.
o Protocols concerning the application of chemoprophylaxis.
• Train nurses in patient management; including admission or referral, triage, diagnosis, treatment, patient
flow and tracking, discharge and follow-up, and also management of support services, pharmacy services,
and logistics and supply functions.
• Ensure that nurses and ward boys involved in patient management receive training and participate in
regular exercises in order to implement the hospital's emergency response.
• Ensure clinical and non-clinical staff receive training and participate in regular exercises in order to
implement infection control measures.
• All HCPs must be trained and made familiar with the patient management protocols outlined in Section
11. These include how to respond to a case of an emerging respiratory virus such as the novel coronavirus,
how to identify a case once it occurs, and how to properly implement IPC measures to ensure there is no
further transmission to healthcare workers or other patients. WHO has also a similar course listed online:
Infection Prevention and Control (IPC) for COVID-19 Virus
• Ensure that patient management protocols for epidemic or other emergencies are widely available to
relevant staff within and outside the hospital.
• Train existing nurses operating in OPD and ward areas to meet the incremental workforce demand in ICU
and step-down units in the following domains:
o General care of patients admitted to the ICU.
o Assist with emergency management and critical procedures of ICU patients.
o Track the results of investigations and inform the doctor on duty as required.
o Identify stable patients who can be shifted to a step-down area when demand for ICU beds
increases.
o Administer prescribed medications on time and monitor patients for effects of medication.
o Prepare ICU report to be submitted to the relevant authorities.
NON-CLINICAL SUPPORT STAFF
The quality of care provided by the hospital depends, among other things, on the quality of essential hospital
support services provided by non-medical staff as part of the overall hospital response to an emergency.
• Conduct an initial information session and subsequent training infection prevention for all non-clinical staff,
and follow all control protocols while on duty, including:
o Regular reporting of symptoms to department as per protocol.
o Re-joining protocols post-sick leave or if kept under isolation.
o Protocols concerning the application of chemoprophylaxis.
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Table 13: Training required for HCPs
Department Training required
Ward boys
• Training in the use of Standard and Additional IPC measures, including use of PPE, consistent with the hospital’s PPE use plan.
• Measures to prevent food-borne disease and ensure the safe management of food waste.
• Personal protection procedures when preparing and transporting dead bodies and in performing autopsies.
Housekeeping
• Training in the use of Standard and Additional IPC measures, to ensure occupational safety and compliance with infection control requirements (coordination between clinical staff and waste management and cleaning staff is essential to prevent or control infectious diseases in a hospital).
• Perform regular cleaning and disinfection procedures likely to reduce transmission.
Biomedical
• Training in IPC measures, including use of PPE.
• Training to perform roles in an emergency.
• Maintaining sterile laboratory requirements and ensuring the availability of laboratory cleaning equipment.
Engineering
• Establish lifeline services and install medical equipment.
• Identify critical hospital areas (like ICU) where maintenance staff are likely to require special equipment or perform special procedures.
• Training in IPC measures accounting for special circumstances and risks (including risk of infection) in emergencies, such as access to high-risk hospital areas (isolation rooms, the emergency department and triage areas).
Desk staff
• Training to implement the hospital's emergency response.
• Implementing emergency communications strategies.
• Procedures required for two-way communication between hospital management and staff to respond in an emergency.
• Provide staff with essential information about personal and family health and welfare; progress reports on the management of the emergency, including actions planned in response to the emergency; official announcements issued by the Ministry of Health or other sources.
• Mechanisms to refer patients to other healthcare levels and for subsequent follow-up, thereby preventing hospital overload.
• Training to allow or disallow patients to enter the OPD, based on answers to preliminary questions about observed coronavirus symptoms.
• Contingency or surge capacity plan for managing staff shortages and for ensuring staff have the skills to meet the increased demand for communications services.
Security
• Liaise with local security services, such as police and fire-fighting services.
• Monitor security risks to staff and patients.
• Perform tasks inside and beyond the hospital perimeter throughout the emergency.
• Train security staff to operate in the identified areas that will need to be opened for COVID-19 patients while following all IPC measures.
Logistics • Training in regular exercises to implement the hospital's emergency response.
• Inventory audit to ensure hospital supply chain is not disrupted.
Volunteers
• Procedures to be followed in an emergency, security issues, IPC measures, cleaning and sterilisation procedures, use of PPE and access to occupational health services.
• Assist regular clinical staff in performing their respective functions.
• Assist clinical nurses in OPD and ward management.
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11.2. TRAINING COURSES
Recommended training courses:21, 22
• WHO: Infection Prevention and Control (IPC) for COVID-19 Virus
• WHO: Clinical Care Severe Acute Respiratory Infection Training
• Occupational Health and Safety Administration: Respiratory Protection
• National Safety Council: Personal Protective Equipment Training
• National Safety Council: Infection Control Training
• TACT: Basic Life Support Online Training
• INSCOL: American Heart Association-accredited workshops
• Columbia India Hospitals: Basic Life Support and Advanced Cardiovascular Life Support
• WHO: Emergency Triage Assessment and Treatment (ETAT)
• WHO: Emerging respiratory viruses, including COVID-19: methods for detection, prevention, response and
control
• WHO: Coronavirus disease (COVID-19) technical guidance
12. PREPARATION FOR SURGE INFLOW
12.1. MAPPING WORKFORCE EXPANSION POTENTIAL
To prepare for the surge capacity demands on a healthcare workforce, it is important to identify methods to
manage these possible scenarios. Surge management strategies are as follows:
• Identify healthcare workforce available for surge capacity demands.
• Repurpose and upskill manpower for rapid deployment to meet surge capacity needs.
• Mobilise temporary healthcare workforce to enable surge capacity.
• Map and expand pool of critical and intensive care staff.
• Ensure protection of frontline healthcare worker by strict adherence to IPC measures.
• Take measures to cater to mental health needs of healthcare workers.
• Hire non-governmental and private healthcare workforce capacity.
• Increase home-based service support by appropriately trained, remunerated and community health
workers and COVID-19 volunteers.
DOCTORS
• Use fit retirees for non-COVID-19 service roles.
• Introduce a web portal featuring junior residents, MD residents, retired professionals and private providers,
able to provide non-COVID-19 essential services.
NURSES AND WARD BOYS
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• To ensure the availability of adequate ICU staff, nurses and ward boys from wards and OPD units can be
reallocated to ICU and stepdown areas. All such staff must be provided with ‘crash course’ training on ICU
care.
• WHO provides online training through tailored courses, such as the 'Clinical Care Severe Acute
Respiratory Infection' online course, intended for clinicians (nurses and healthcare workers) working in
ICUs in low and middle-income countries. This ten-hour course is a hands-on practical guide for healthcare
professionals involved in clinical care management during outbreaks of seasonal influenza virus, human
infection due to avian influenza virus (H5N1, H7N9), MERS-CoV, COVID-19 and other emerging respiratory
viral epidemics. Clinicians can enroll for free by registering on OpenWHO.
HOUSEKEEPING AND BIOMEDICAL
• To address increasing pressure on dirty utility staff, housekeeping staff can be trained and allocated towards
waste management, including the treatment and disposal of waste contaminated by coronavirus.
• Biomedical staff can operate on shifts, rotating between carrying out laboratory tests and performing
clinical and non-clinical waste disposal.
SECURITY
• Front-line security can be deployed to screen patients requiring consultation for COVID-19 based on
cold/fever symptoms (through COVID-19 detection equipment).
12.2. ADDITIONAL ROLES AND RESPONSIBILITES
MEDICAL DIRECTOR
• Update entire hospital regularly on guidelines and IPC measures as per CDCP/WHO/other reliable sources.
• Revaluate of elective surgeries, procedures and OPDs, streamlining the same for rescheduling/building
proper measures for unavoidable procedures.
• Introduce containment measures in case of outbreak/detection of COVID-19 positive patients in the
facility.
• Regulate emergency services and staffing, improve emergency response and ambulance service protocols,
and regulate patient home visits.
• Implement training programmes for workforce rationalisation.
• Ensure essential vaccinations for staff.
• Implement protocols for previously quarantined staff re-joining the workplace.
• Introduce inter-hospital communication and transportation protocols.
• Ensure regular communication and status updates with government and health officials.
• Introduce a system to prioritise patient treatment, protocols for medical staff treatment and monitoring,
including temperature and symptom checks before each shift.
• Conduct surge capacity planning.
• Introduce a contingency plan for monitoring and managing post-mortem care.
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NURSE TEAM LEADERS
• Regulate the sterilisation of consumables and equipment.
• Ensure regular implementation of guidelines and IPC training as required.
• Implement relevant training on the deployment of nurse teams and workforce rationalisation.
• Assign nursing officers to departments to ensure incoming officers and staff to the quarantine building are
wearing appropriate PPE. Ensure officers are aware of universal infection control precautions along with
appropriate disposal of waste, PPE, etc.
CHIEF OF BIOMEDICAL
• Distribute regular updates on biomedical guidelines and information relating to COVID-19.
• Implement proper waste management protocols.
• Update lab procedure regulations.
• Provide training to all healthcare workers and others involved in the handling of biomedical waste.
• Provide safe, secure and ventilated areas/locations for the storage of segregated biomedical waste within
quarantine facility premises.
• Provide legal authorisation and access to waste collection vehicles.
• Ensure proper coordination and communication with the biomedical waste management company
associated with the quarantine facility.
• Supervise IPC in the facility in coordination with the microbiologist/clinician.
CHIEF OF ENGINEERING
• Regulate air ventilation and filters as required.
• Plan and deploy physical barriers and passageways for patients, staff and visitors.
• Ensure the preparation of isolation rooms.
CHIEF OF OPERATIONS
• Ensure management of medical stores, including telemedicine services.
• Implement containment and preparedness training for non-clinical staff and patients.
• Install a remote communication systems for clinical staff, patients and visitors.
HEAD OF HOUSEKEEPING
• Ensure infection control training is administered and updated regularly as required.
• Supervise the replacement of alcohol-based sanitisers across facilities.
• Upscale the frequency of sanitation measures as per new guidelines.
HEAD OF DOCUMENTATION
• Create a new or revised system to update staff on regulations, guidelines, protocols and patient status.
• Improve patient documentation systems.
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HEAD OF STORES
• Regulate the supply and distribution of PPE equipment.
• Ensure proper supplies for sanitation and fumigation.
• Develop strategies for managing cases of materials and equipment shortages.
• Update systems to ensure better tracking of materials and equipment.
HEAD OF SECURITY
• Plan and implement security protocols for screening.
• Introduce security measures for all entry points and passageways.
• Set up tagging system for symptomatic patients and visitors.
• Ensure 24-hour manning of all facility posts.
• Ensure implementation of PPE and infection control training for security staff.
• Maintain record of entry and exit logs for patients, doctors and nurses, and update the controlling authority
daily.
• Implement appropriate rotational shifts for security personnel and management to meet surge capacity
requirements.
13. STAFF MENTAL HEALTH
• Keep staff protected from chronic stress and poor mental health during this response so they will have a
better capacity to fulfil their roles.
• Ensure staff take sufficient rest and respite during work or between shifts, eat sufficient and healthy food,
engage in physical activity, and stay in contact with family and friends.
• Rotate workers from higher-stress to lower-stress functions. Partner inexperienced workers with more
experienced colleagues. A buddy system can provide support, monitor stress and reinforce safety
procedures.
• Implement flexible schedules for workers who are directly impacted or have a family member affected by a
stressful event. Include time for colleagues to provide social support to each other.
• Ensure staff members are aware of how and where they can access mental health and psychosocial support
services and make it easy for staff to access such services.
• Encourage staff to avoid unhelpful coping strategies (such as tobacco, alcohol or other drugs) which can
worsen their long-term mental and physical wellbeing.23
14. APPENDIX - CHECKLISTS
FACILITIES AND INFRASTRUCTURE CHECKLIST: COVID 19 FACILITY 24,25
S.No. Parameter Sub-parameter
Available? (Yes/No/In Progress)
1 Infection prevention and control practices: across facility
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1.1 Space routing Have passages been demarcated for unidirectional flow of patients, medical consumables, contaminated items and staff?
1.2 Patient flow Are there protocols for minimising movement of COVID patients outside the isolation ward?
1.3 Visitor restriction
Are visitors screened for symptoms before entry to the premises?
Are there policies to minimise the number of visitors for COVID as well as non-COVID patients?
Are there protocols for remote communication between patients and their family?
1.4 Staff
Guidelines for rational use of PPE by the staff including donning and doffing guidelines
Self-monitoring of symptoms
Physical distancing guidelines (including prevention of overcrowding)
Staffing rationalisation to minimise exposure
1.5 Supplies
Are there posters to reinforce hand washing and PPE at hand washing stations?
Are there functioning hand washing stations (including water, soap and paper towel/air dry) at isolation area?
Does the facility have an uninterrupted running water supply?
Alcohol-based hand sanitiser available at the isolation area?
1.6 Cleaning
Availability of terminal cleaning checklist
Availability of three bucket system
Availability of separate mops for each area
Protocol for disinfection of wards (isolation and others)
Disinfection of high-touch surfaces
Disposal of blood and body fluid spills
Disinfection of reusable medical equipment/devices
Disinfection of infectious fabrics
Disposal of biomedical waste
1.7 Waste management
Is there sufficient availability of colour-coded bags?
Is a biomedical waste trolley available?
Is there a dedicated biomedical waste collection area?
1.8 Other services
Is there sufficient availability of body bags?
Is there a designated ambulance facility for transporting patients from the isolation area?
1.9
Sharing of existing hospital infrastructure
Has separate radiology/diagnostic equipment been earmarked for use suspect/confirmed COVID-19 patients?
If equipment is to be shared, has rostering been done?
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If equipment is to be shared, have sanitation and disinfection protocols been defined?
1.10 Documentation Have IPC SOPs relating to handling COVID-19 patients been documented?
2 Triage area
2.1 Guideline documents
Screening questionnaire and algorithm for triage available with staff (temperature, SPo2, history of travel, history of symptoms)
2.2 Infrastructure
Availability of designated ARI/COVID-19 triage area
Waiting area for people with respiratory symptoms
Single examination rooms in triage area (dedicated room should satisfy criteria of one patient per room with door closed for examination)
Does the patient waiting area have cross ventilation?
Telemedicine facility to provide clinical support without direct interaction with the patient
2.3 Appropriate signage
Are signs available that direct patients to the triage area and instruct patients to alert staff if they have COVID-19 symptoms?
Does the triage area display signs/alerts about respiratory etiquette and hand hygiene?
2.4 Supplies
Is a non-contact infrared thermometer available near the registration desk?
Are masks provided for patients with respiratory symptoms?
Do triage staff have access to an infrared thermometer?
Are waste bins and access to cleaning and disinfectant supplies available in the triage area?
Are physical barriers (glass or plastic screens) at reception areas available – limiting close contact between triage staff and potentially infectious patients?
3 Isolation facility
3.1 Layout
Is the isolation facility near OPD/IPD/other crowded area?
Is the isolation facility separate with rooms/wards?
Screening rooms at the isolation area?
Separate entry to isolation area?
Separate exit to isolation area?
Is there a dedicated space near the exit for staff to remove PPE?
Is there any designated area for sample collection?
Are washrooms available as one toilet per 20 persons?
Is the distance between two beds in isolation wards/rooms more than one metre?
Are the floors of isolation facility suitable for moping?
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Are these isolation rooms/wards satisfying the criteria of negative pressure class N? (Applicable if an aerosol generating procedure is performed)
3.2 Utilities
Is there provision for food in the isolation area?
Availability of cross ventilation
Is drinking water available at the isolation area?
Availability of visual indicators for air pressure is monitoring (e.g., smoke tubes, flutter strips), regardless of the presence of differential pressure-sensing devices (e.g., manometers)
3.3 Supplies
Whether PPEs available and located near point of use - gloves
Whether PPEs available and located near point of use – gowns
Whether PPEs available and located near point of use – facemasks
Whether PPEs available and located near point of use – 95 respirators
Availability of separate Thermometers BP apparatus with adult and paediatric?
3.4 HVAC
Outdoor air ventilation
Addition of highly-efficient particle filtration (HEPA and/or ULPA) to central ventilation systems to reduce the airborne load of infectious particles
Outdoor air intakes should be located at least nine metres from any Class 4 air exhaust discharges
Exhaust air outlets should be located a minimum of three metres above ground level and away from doors, occupied areas, and operable windows
Patients are isolated in individual isolation rooms or negative pressure rooms with 12 or more air changes per hour
Anteroom with following pressure relationship: (1) aII rooms at a negative pressure with respect to the anteroom, and (2) the anteroom at a negative pressure with respect to the corridor
4 ICU facility
4.1 Layout
Is there an ICU facility attached to isolation area?
Are there any beds dedicated for COVID-19 infection?
Hand washing facilities and hand sanitiser available at donning and doffing areas?
Is the distance between beds in ICU more than one metre?
Availability of oxygen supply by cylinder or central connection?
Are there separate areas for donning and doffing of PPE?
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4.2 Equipment
Are there any separate ventilators, nebulisers, infusion pumps in ICU?
Adequate supply of masks, ET tubes, PPE kits available at ICU?
5 Other protocols
5.1 Staff
Guidelines for ensuring good staff mental health
Ongoing training for clinical/non-clinical staff to ensure implementation of protocols
Procedure for remedial action against exposure
Rostering and deployment calendar prepared for HCPs (in triage, isolation and ICUs)
Training given to HCPs in keeping with MoHFW and WHO guidelines
Rostering and deployment calendar prepared for non-clinical/support staff
Training given to non-clinical/support staff
Duty and self-quarantine protocol defined for HCPs
5.2 Patient management
Protocol for triage
Guidelines for testing and diagnosis
Discharge and follow-up protocol
Protocols after death
Guidelines for surge inflow (contingency)
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STAFF PREPAREDNESS AND PLANNING
The following measures can be taken by staff to support healthcare facility preparedness26
Table 14: Doctor preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet (symptoms)
Collection of PPE for each shift
Log department assignment
Update on self-vaccines (one-time update)
Midday
Limit/reduce/redirect non-essential outpatient department visits in case of
direct or indirect contact with COVID-19 cases
End of day
Report damaged PPE
Disposal of used PPE
Report any offsite patient visit
Check-out sheet
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Table 15: Nurse preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department assignment
Sterilisation of all equipment
Update on self-vaccines (one-time update)
Midday
Disinfect surfaces between patient consults
Lab specimen management
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
Disposal of all consumables
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Non-clinical support staff
Table 16: Ward boys preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department/patient/room assignment
Undergo protocols training for detection of COVID-19 patient
(including transport of patient)
Midday
Appropriate management of patient meals and non-clinical services
Ensuring regular clean-up/disinfection/fumigation of rooms
Regular replacement/cleaning of patient essentials (clothes, utensils, etc.)
Regular patient check on symptoms (self/by nurse)
Self-sanitation between patient visits at regular intervals
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
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Table 17: Housekeeping preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department/room assignment
Placing waiting room chairs at considerable distance
Replacement/washing of bedsheets and linens
Undergo/update training for management of infectious material including
disposable PPE equipment, waste management, etc.
Mid-day
Regular room cleaning/disinfecting as required
Regular refurbishment of hand sanitisers and other essentials for patients
and staff
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
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Table 18: Biomedical team preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department/room assignment
Ensure deployment of equipment/staff as per requirement
Training/updating staff on biomedical waste management
Midday
Regular replacement of equipment by department requirement
Lab procedure protocol updates
Develop and implement protocols for aerosol-generating procedures
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
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Table 19: Store preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Inventory log-in
Disinfecting/cleaning room
Waste management check
PPE deployment and inventory check
Midday
Regular room cleaning
Inventory check by clinical/non-clinical essentials
Buffer creation for PPE and other staff essentials
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
PPE requirement update
Sanitation of all returned daily use essentials
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Table 20: Engineering preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department/room assignment
System check for entire hospital
Repair or replacement of essential services
Midday
Regular repair or replacement of hospital systems including HEPA filters
and air ventilators
Installation of curtains in shared rooms
Installation of physical barriers and pathways to transport COVID-19-
infected patients, clinical staff, etc.
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
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Table 21: Desk staff preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department/room assignment
Proper allocation of patients by classification
Midday
Inform patients at outpatient department lobbies and other areas where
protocols and guidelines are to be followed
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
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Table 22: Security preparedness
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Log department/room assignment
Deployment of staff by key regions
Contingency plans – possibly tagging patients being tested for symptoms
and allowing exit only if undergone required protocols/procedures
Undergo training to identify symptoms and protection from exposure
Create passageways for regular patients, Covid-19 risk patients and
clinical staff
Patient passes and visitor passes to be made for all patients
Midday
Restriction plan for patient visitors
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
Return of required testing equipment
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Table 23: IT/documentation and team preparedness records
Protocols Yes/No
Pre-entry/start
Check-in sheet
Collection of PPE for each shift
Entry of departments being approached
Update on hospital protocols/procedures/information and deployment of
required measures accordingly
Regular deployment of staff training on IPC and other training
requirements
Implement a system for distribution of patient status information across
departments and personnel
Midday
Live update of patient status and logbooks of clinical staff
Prepare and maintain updated protocols for patients to follow
End of day
Report damaged PPE
Disposal of used PPE
Check-out sheet
Update patient and clinical staff records
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15. REFERENCES
1 World Health Organisation (March 2020): Operational Considerations for Case Management of COVID-19 in Health Facility and Community 2 Ministry of Health and Family Welfare (2020): Guidance document on appropriate management of suspect/confirmed cases of COVID-19 3 Jack Ma Foundation, Zall Foundation and Alibaba Foundation (2020): Construction and Operational manual of Emergency Hospital: COVID-19 4 Centre for Disease Control and Prevention (2020): Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings 5 TCE and EcoFirst: INDIA’S WAR AGAINST COVID-19 6 University of Washington School of Medicine (2020): Coronavirus: Visitor Policy 7 Centre for Disease Control and Prevention (2020): Comprehensive Hospital Preparedness Checklist for Coronavirus Disease 2019 (COVID-19) 8 World Health Organisation (March 2020): Global surveillance for COVID-19 caused by human infection with COVID-19 virus (interim guidance) 9 World Health Organisation (May 2020): Clinical management of COVID-19 10 Government of India Ministry of Health and Family Welfare (March 2020): Revised Guidelines on Clinical Management of COVID-19 11 Centre for Disease Control and Prevention (June 2015): Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) 12 European Centre for Disease Prevention and Control (2020): Novel Coronavirus (SARS-CoV-2): Discharge criteria for confirmed COVID-19 cases 13 World Health Organisation (March 2020): Infection Prevention and Control for the safe management of a dead body in the context of COVID-19 14 World Health Organisation (April 2020): Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) and considerations during severe shortages 15 World Health Organisation (March 2020): Infection prevention and control during health care when COVID-19 is suspected
16 JIPMER (2020): Infection Prevention and Control (IPC) SOP for COVID-19 17 Zhejiang University School of Medicine, LIANG, Prof. Tingbo (2020): Handbook of COVID-19 Prevention and Treatment
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18 Ministry of Health and Family Welfare (2020): Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective Equipment 19 Centre for Disease Control and Prevention (2020): Sequence for putting on Personal Protective Equipment 20 Central Pollution Control Board (2020): Guidelines for Handling, Treatment and Disposal of Waste Generated during Treatment/Diagnosis/Quarantine of COVID-19 Patients 21 National Safety Council: online training courses 22 Open WHO: online training courses 23 World Health Organisation (2020): Mental health and psychosocial considerations during the COVID-19 outbreak
24 National Centre for Disease Control (2020): COVID-19 Outbreak: Guidelines for Setting up Isolation Facility/Ward 25 Centre for Disease Control and Prevention (2020): Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and Other Long-Term Care Settings