Some Best Practise Findings in Treatment of COVID-19 from INDIA
a short abstract published here by Dr. Walter Lipke, Kenya/Germany
Especially useful for doctors/health care workers who are managing COVID-19 patients
Source: Department of Community and Family Medicine, AIIMS Raipur
MUST KNOW AS A DOCTOR
- Who are your patients?
Answer: All suspect cases with or without test results Suspect case (a) A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness of breath), AND with no other etiology that fully explains the clinical presentation AND a history of travel to or residence in a country/area or territory reporting local transmission of COVID – 19 disease during the 14 days prior to symptom onset. OR (b) 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 onset of symptoms; OR (c) A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness of breath) AND requiring hospitalization AND with no other etiology that fully explains the clinical presentation.
- When are health care workers under risk during management of COVID-19 patients?
Answer: Whenever health care workers become a contact. Working with suspects while not maintaining 6 feet distance and not performing hand hygiene frequently. A contact is a person that is involved in any of the following: Providing direct care without proper personal protective equipment (PPE) for COVID19 patients Staying in the same close environment of a COVID-19 patient (including workplace, classroom, household, gatherings) Travelling together in close proximity (1m) with a COVID-19 patient in any kind of conveyance within a 14 day period after the onset of symptoms in the case under consideration.
- Is COVID-19 dangerous for doctors and other health workers? Answer: Evidences of infections among healthcare workers are being gradually published but the evidence at the moment is low. But known facts are as follows https://www.journalofhospitalinfection.com/article/S0195-6701(20)30101-8/fulltext
Until 24th February, NHCPRC (The National Health Commission of the People’s Republic of China) reported in press conference of WHO-China Joint Mission on COVID-19 that:
- 3,387 healthcare workers have confirmed infected COVID-19, with 22 (0.6%) deaths.
- More than 90% of infected healthcare workers were from Hubei province, the epicenter of the outbreak The reason for possible infections were a. First, inadequate personal protection of healthcare workers at the beginning of the epidemic was a great issue. In fact, they did not understand the pathogen well; and their awareness of personal protection was not strong enough. Therefore, the front-line healthcare workers did not implement the effective personal protection before conducting the treatment.
- Second, long-time exposure to large-scale of infected patients directly increased the risk of infection for healthcare workers. Also, pressure of treatment, work intensity, and lacking of rest indirectly increased the probability of infection for healthcare workers.
- Third, shortage of personal protective equipment (PPE) was also a serious problem. First Level emergency responses have been initiated in various parts of the country, which has led to a rapid increase in the demand for PPE. This circumstance increased the risk of infection for healthcare workers due to lacking of sufficient PPE.
- Fourth, the front-line healthcare workers (except infectious disease physicians) received inadequate training for IPC (Infection prevention and control), particularly lacking of the knowledge of IPC for respiratory-borne infectious diseases.
- Can we save our health workers?
Answer: Yes we can, evidences are here (narrated by Dr. Atul Gawande, author & doctor, of good authenticity)
Story 1: From Wuhan
In the index outbreak in Wuhan, thirteen hundred health-care workers became infected; their likelihood of infection was more than three times as high as the general population. When they went back home to their families, they became prime vectors of transmission. The city began to run out of doctors and nurses. Forty-two thousand more had to be brought in from elsewhere to treat the sick
Catch: None of the new batch of doctors fell ill. Zero infected after that.
Story 2: Hong Kong & Singapore,masks, and, at first, test
2 countries have different stories to tell than the rest of world. Both countries detected their first cases in late January, and the number of cases escalated rapidly. Officials banned large gatherings, directed people to work from home, and encouraged social distancing. Testing was ramped up as quickly as possible. But even these measures were never going to be enough if the virus kept propagating among health-care workers and facilities. Primary-care clinics and hospitals in the two countries, like in the U.S., didn’t have enough gowns and N95 s weren’t widely available. After six weeks, though, they had a handle on the outbreak. Hospitals weren’t overrun with patients. By now, businesses and government offices have even begun reopening, and focus has shifted to controlling the cases coming into the country. Catch: Singapore has not recorded a single case healthcare worker infection till now (date: 19/3/20) even after dealing with hundreds of test positive patients.
Key policies they adopted:
- All health-care workers are expected to wear regular surgical masks for all patient interactions, to use gloves and proper hand hygiene, and to disinfect all surfaces in between patient consults.
- Patients with suspicious symptoms (a low-grade fever coupled with a cough, respiratory complaints, fatigue, or muscle aches) or exposures (travel to places with viral spread or contact with someone who tested positive) are separated from the rest of the patient population, and treated in separate ward, separate location by a separate team of doctors.
- Social distancing is practiced within clinics and hospitals: waiting-room chairs are placed 6 feet apart; direct interactions among staff members are conducted at a distance; doctors and patients stay 6 feet apart except during examinations.
- N95, face-protectors, goggles, and gowns are reserved for procedures where respiratory secretions can be aerosolized (for example, intubating a patient for anesthesia) and for known or suspected cases of covid-19. ● Doctors, who were close contacts, (exposure with a COVID-19 patient for more than 15 min within 6 feet distance) were put on home isolation. ● If there is no breach in the above said limit, workers can stay on the job if they wear a surgical mask and have twice-daily temperature checks.
After going through a lot of published documents we are of the view
- PPE according to place of posting is must. PPE of OPD, IPD and infectious ward are different.
- Train yourself regarding PPE and infection control through WHO documents or authentic YouTube videos before posting. (Some given here)
- Strict social distancing of 6 feet (according to WHO 3 feet) among patients, patient and doctors are must except minimum duration of examining the patients.
- Separation of patients having respiratory symptoms from other patients in OPD or IPD is must.
- If anytime N95 masks fall short, only surgical mask, proper hand washing, 6 feet distance and gloves during examination has proved extremely effective in Singapore. So we are confident it will be as effective here also.
- Strict mobile phone or electronic device hygiene at workplace is recommended. (Described below)
- Reveal your status to authority; whenever you feel there is a breach of PPE during attending a COVID-19 patient, or unprotected exposure with COVID-19 patient for more than 2 min within 6 feet distance.
- Convey your comorbidity status to the Head of departments.
- At any point of time if you feel, you are exposed to a COVID-19 suspect beyond limit then keep yourself in home isolation (How to prepare? Described below) immediately with twice daily temperature monitoring for 14 days. Convey the same to administration via mail.
- Remember, home quarantine or home isolation as and when required, though difficult is a necessary step to protect you and your family. (Explained below)
- When is someone infectious?
Answer: The onset and duration of viral shedding and period of infectiousness for COVID-19 is not yet known. 8 | P a g e The role of pre-symptomatic transmission (infection detection during the incubation period prior to illness onset) and transmission from asymptomatic infection with SARS-CoV-2 are unknown. The incubation period= 2 to 14 days From symptomatic patients, person-to-person transmission appears to occur similar to other respiratory viruses, mainly via respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs. Less predominant mode of transmission- touching a surface contaminated with the virus and then touching their own mouth, nose, or eyes Mortality rate : 2-4% (Reference:https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html)
- Are you a suspect case?
Answer: A patient/health care worker with any acute respiratory illness AND having been in contact with a confirmed COVID-19 case in the last 14 days prior to onset of symptoms
- Are you a High Risk Contact?
Answer: Touched body fluids of the patient (Respiratory tract secretions, blood, vomit, saliva, urine, faeces) Had direct physical contact with the body of the patient including physical examination without PPE. Anyone in close proximity (within 3 feet) of the confirmed case without precautions
- Are you a Low Risk Contact?
Answer: Shared the same space (Same class for school/worked in same room/similar and not having a high risk exposure to confirmed or suspect case of COVID-19)
- How to protect yourself?
Answer: – Source control: put a mask on the patient |
Ensure appropriate patient placement in a single room if possible – Use personal protective equipment (PPE) appropriately – Limit transport and movement of patients outside of the room to medically-necessary purposes
- Disposal of PPE – Where? When? How?
Answer: Do’s: Dispose all components of PPE, in the ward or OPD itself according to the BMW protocol. Don’ts: Don’t carry the PPE to your home or any shops or any evening hangout places Don’t dispose the PPE in dust bin common for general wastes
- Precautions to be taken, at home, after duty
Answer: Disinfect all your belongings like clothes, pen and mobile phones Wash your hands with soap and water as soon as possible Stay in a well-ventilated single-room preferably with an attached/separate toilet. If another family member needs to stay in the same room, it’s advisable to maintain a distance of at least 1 meter between the two. Needs to stay away from elderly people, pregnant women, children and persons with comorbidities within the household. Restrict his/her movement within the house Under no circumstances attend any social/religious gathering e.g. wedding, condolences, etc.
MOBILE PHONE HYGIENE
- Mobile phones are among very few devices which can touch your face directly while talking over phone. So can spread infection even if hands are properly washed.
- It can effectively negate effect of hand hygiene as compulsively we touch mobile after hand washing
- It has both glass & plastic surface. Virus can survive up to 72 hours on plastic.
- The mobile is neither disposable or washable.
Hence recommendations are
- Compulsory use of earphones.
- Washing of hand after using mobile phone.
- Cleaning mobile phones with at least 70% alcohol/ hand sanitizer ( isopropyl alcohol recommended by apple.
- Clean once before leaving hospital premise.
HOME QUARANTINE and HOME ISOLATION
Home quarantine – Close contacts of confirmed cases of COVID-19. People who have been in countries covered by the quarantine decision.
People who are in quarantine and who develop symptoms of respiratory infection should be in home isolation until they are recovered, and for a minimum of 14 days after quarantine began. Home isolation Home isolation applies for Confirmed cases, i.e., those who are confirmed with COVID-19, but do not need to be admitted to hospital.
People with symptoms of respiratory infection and are being tested for COVID-19. Duration of home quarantine or home isolation Close contacts must be in home quarantine for 14 days after the last contact with the patient diagnosed with the virus.
This also applies even though you may have tested negative for coronavirus during the period Close contacts who are household members of people isolated with COVID-19 must be in home quarantine until home isolation for the patient ceases, and for a minimum of 14 days after quarantine began.
I was send this just today by my friends from NEW DELHI. It refelcts the Findings of Senior Residents and Junior Residents Department of Community and Family Medicine AIIMS, from RAIPUR, INDIA.
As I personally believe that it is very efficient to learn to handle the coronavirus crisis best by sharing experiences and best practise examples worldwide I have decided to publish this here today.
It may especially help those that are in daily contact with patients everywhere while fighting the COVID-19 pandemia.
May God bless all the medical staff, good workers and helpers on the ground. And may we all take the precautions mentioned here and elsewhere otto stay safe and healthy. That’s our continuous prayer.
Stay all safe please.