Clinic Establishment and Practice Guidelines for Coronavirus Patients (For attention of Doctors)

India

healthysoch

New Delhi, March 24, 2020 :

Safe practice guidelines for doctors

• Provide as many paid tele consultations as possible for next two weeks.
• Doctors aged more than 65 years with uncontrolled diabetes, immunocompromised, who have six minutes’ walk distance< 200 meters, are unvaccinated for flu and pneumonia (with common secondary or co-infections) should completely stop OPDs and only give tele consultations.
• Always wear surgical masks; if doing any procedure where aerosols may be produced, use N95 masks.
• Doctor with cough and fever should go for self-quarantine and COVID assessment, In a WHO study from Italy, it has been shown that 90% of doctors attending patients were asymptomatic when they were tested COVID-19 positive.
• Install air purifiers with 10 air exchanges per hour rate at the clinic

 While returning home

• When you come back home from you clinic, wash feet first, then hands, face, change cloths (keep them in separate box for washing), decontaminate all surfaces you have touched including your car, wash hands again with soap and water.
• Stay away from elderly people in your home if possible.

Caution: Your young children should not be looking after your parents.

Have important phone numbers read

COVID ambulances, Local DSO, COVID hospitals

Inform through SMS

Inform all patients that if they or any close contact has and fever they should call first and not visit the clinic/hospital without tele consultation.

Educate the staff about hand wash, respiratory and personal hygiene and cough etiquette

Hand wash: Any soap and water, 20 seconds, >60% alcohol sanitiser,

Respiratory hygiene: cough and sneeze on tissue paper or sleeves

Cough: Maintain a distance of 1-2 meters

Provide access to surgical masks, liquid soap & sanitizers to all staff

Use N 95 mask if the staff is involved in any procedure producing aerosol including high pressure oxygen

Build Immunity

Educate every one about good food, rest, walks

Allow non-essential staff to work from home

Accounts, PRO, relationships

Use infrared thermometers at the reception desk

Check temperature of everyone entering the premises

Practice social distancing

• Call patients with appointments to avoid crowding at reception / waiting area
• Make them wait in their car and inform them through phone when their appointment is due
• Provide separate waiting area for suspected COVID-19 patients (six feet distance)
• If possible make all OPD patients wear masks

Take undertaking

Make all patients give an undertaking that they or their family member is not having cough and fever.  They should also disclose about any international travel of any family member/friend/visitor

Staff traveling by train

• Make them aware through infection control tutorials
• Have a backup ready to cover for ill staff

While examining patients

• Keep a distance of three feet, examine chest from back, make patient not sit face to face but face to side
• If possible, run special cough cold and fever OPD for one hour at a fixed time
• Remember cold and stuffy nose is present only in 4% of COVID 19 patients. It is flu unless proved otherwise.
• Postpone non emergent cases or see them on video call

Stock essential medical supplies

• Make a plan to handle rise in cases and hence increased patient volume (worst 0.1% of your area)
• Maintain supply of masks, disinfectant/sanitizer and other personal protective equipment

 Disinfect three times a day

• Disinfect all things that you touch during work; including computers, keyboards, scanners, door handles, BP instrument, stethoscope, SPO₂monitor, room with 0.1% bleach solution three times a day
• Keep hand sanitizer at all strategic points like reception, procedure rooms, reporting rooms etc.

Home care

Patients with mild infection who can be adequately isolated in the outpatient setting:

• Management strategy should focus on the prevention of transmission and regular monitoring for clinical deterioration of the condition which should require hospitalization of the patient.
• COVID-19 patients who are not hospitalized, should stay at home and away from other people and pets in the household
• Infected patients should wear a facemask when in the same room (or vehicle) as other people and when visiting the doctor/health care facilities
• They should periodically disinfect the frequently touched surfaces

Test-based strategy:

Home-isolation for infected patients should be discontinued in following conditions;

• Resolution of fever without the use of fever-reducing medications AND
• Improvement in respiratory symptoms (e.g. cough, shortness of breath) AND
• Negative results of a US Food and Drug Administration (FDA) Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens)

Non-test-based strategy:

Home-isolation for infected patients should be discontinued in case any of the following criteria are met;

• At least seven days have passed since symptoms first appeared AND
• At least three days (72 hours) have passed since recovery of symptoms (defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms [e.g. cough, shortness of breath])

Certain patients may have had laboratory-confirmed COVID-19, but they may have been asymptomatic when they were tested. In these patients, home isolation may be discontinued when at least seven days have passed since the date of their first positive COVID-19 test if there has been no evidence of subsequent illness.

The non-test based strategies where time since illness onset and time since recovery acts as the criteria for discontinuing precautions is based upon research results that transmission is most likely to occur in the early stage of infection. However, data are limited, especially in immunocompromised patients, and this strategy may not be effective in preventing all types of secondary infection.

Tests

• Lymphocyte count: day 1. 7 and 14. Persistent low lymphocyte count is a bad sign.
• D dimer > 1 on first visit is a bad sign
• SPO2 < 90 is emergency
• Exertional fall of SPO2 > 4% with cough is a sign of early respiratory decompensation
• High risk patients: six minutes’ walk distance < 200 meters, uncontrolled BP, sugar and heart failure
• Do not ignore fever with cough, fever and low lymphocyte counts
• Prophylaxis for health care providers, high risk case
• Flu and pneumonia vaccine to all high-risk cases

Off label use: chloroquine 2 tablets per week/ or 2 tablets of hydroxy chloroquine2oo mg  per week may be considered in high risk patients (elderly, patients with comorbid conditions, six-minutes’ walk distance < 200 meters) and healthcare providers handling the COVID like

Treatment

• Throat swab for COVID 19, hemogram (lymphocyte count), CRP< LDH, D dimer, early CT chest, six minutes’ walk distance
• Start any Tamiflu brand 1 BD for five days
• Off label use:  Hydroxychloroquine (200 mg three times per day for 10 days) plus Azithromycin 500 mg once daily for ten days in all COVID suspected or confirmed cases
• Off label use in  high risk cases (determined by persistent leukopenia on day 7, high SOFA score or D Dimer > 1); add Lopinavir 400 mg/ritonavir 100 mg twice daily or Lopinavir 800 mg/ritonavir 200 mg once daily can be added. This has also been approved by DCGI.

Quarantine policy

• Quarantine staff after exposure to patients with suspected coronavirus.
• Get COVID throat swab done of all high-risk contacts at day 5

Serious cases

• Patients with severe disease often need oxygenation support
• High-flow oxygen
• Non-invasive positive pressure ventilation
• They are aerosol-generating procedures that warrant specific isolation precautions.
• Some patients may develop acute respiratory distress syndrome and require intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia.

Meaning od isolation,quarantine and social distancng 

Author :Dr KK Aggarwal (President CMAAO); Dr Rajan Sharma (National President IMA); Dr R V Asokan (HSG IMA); Dr V K Monga (Chairman HBI)