Infection Prevention Control Guidelines for suspected cases of … IPC... · 2020-04-04 · 1 ATAL...

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ATAL BIHARI VAJPAYEE INSTITUTE OF MEDICAL SCIENCES

&

DR RAM MANOHAR LOHIA HOSPITAL, NEW DELHI-110001

DEPARTMENT OF MICROBIOLOGY

Infection Prevention Control Guidelines for suspected cases of

COVID-19/SARS-CoV-2

Clinical triage includes early recognition and immediate placement of patients in separate area

from other patients (source control). A self-declaration form (Annex 1) should be filled up for all

suspected cases reporting to the hospital. All individuals, including family members, visitors and

HCWs should apply standard, contact and droplet precautions. Place patients in adequately

ventilated single rooms. When single rooms are not available, cohort patients suspected of nCoV

infection together.

IPC strategies to prevent or limit infection transmission in health-care settings include the

following:

1. Standard Precautions

1.1 Hand hygiene

1.2 Respiratory hygiene

1.3 Personal protective equipment (PPE)

2. AdditionalPrecautions

3. Environmentalcleaning

4. Bio-medical wastemanagement

5. Laundrymanagement

6. Sample collection, storage and transportation

7. Ambulancetransfer

8. Dead body handling

The guidelines are issued with the approval of the Medical Superintendent, ABVIMS & Dr RMLH.

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1 Standard Precautions

1.1 Hand Hygiene

Moments of Hand Hygiene

Hand hygiene should be

performed

Before touching a patient

Before clean/aseptic

procedure

After body fluid exposure risk

After touching a patient

After touching patients’

surroundings

Hand Hygiene Steps–15-30

sec

Wet hands with soap & water

Apply enough soap

Rub hands palm to palm

Rub back of each hand with

palm of other hand with

fingers interlaced

Rub palm to palm with

fingers interlaced

Rub back of fingers to

opposing palms with fingers

interlock

Rub each palm clasped in the

opposing hand using a

rotational movement

Rub tips of fingers in opposite

palm in a circular motion

Rub each wrist with opposite

hand

Rinse hands with water

Use elbow to turn of tap

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1.2 Respiratory Hygiene

Offer a medical/surgical mask for suspected nCoV infection for those who can tolerate it.

Cover nose and mouth during coughing or sneezing with flexed elbow.

Perform hand hygiene after contact with respiratory secretions.

1.3 Personal Protective Equipment (PPE)

PPE includes shoe cover, gown, mask, eye protection &gloves.

Shoe cover should be worn before entering the patient care area (Isolation wardetc.).

If gowns are not fluid resistant, use a waterproof apron for procedures with expected

high fluid volumes that might penetrate the gown.

Donning & Doffing procedures should be diligently & carefully followed as given below.

Keep hands away from face

Limit surfaces touched

Change gloves when torn or

heavily contaminated

Perform Hand Hygiene

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PERFORM HAND HYGIENE BETWEEN STEPS IF HANDS BECOME CONTAMINATED AND

IMMEDIATELY AFTER REMOVING ALL PPE

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Rational use of personal protective equipment

PPE use is based on the risk of exposure (e.g., type of activity) and the transmission dynamics of the

pathogen (e.g., contact droplet or aerosol). Observing the following recommendations will ensure rational

use of PPE.

1. The type of PPE used when caring for COVID-19 patients will vary according to the setting and

type of personnel and activity (BelowTable).

2. Healthcare workers involved in the direct care of patients should use the followingPPE:

a. gowns,

b. gloves,

c. medical mask

d. Eye protection (goggles or face shield).

3. Specifically, for aerosol-generating procedures (e.g., tracheal intubation, non-invasive

ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation,

bronchoscopy) healthcare workers should use respirators (N95), eye protection, gloves and gowns;

aprons should also be used if gowns are not fluid resistant.

4. Respirators (e.g., N95, FFP2 or equivalent standard) have been used for an extended time during

previous public health emergencies involving acute respiratory illness when PPE was in short

supply. This refers to wearing the same respirator while caring for multiple patients who have the

samediagnosiswithoutremovingit, andevidenceindicatesthatrespiratorsmaintaintheirprotection

when used for extended periods. However, using one respirator for longer than 4 hours can lead to

discomfort and should be avoided.

5. Among the general public, persons with respiratory symptoms or those caring for COVID-19

patients at home should receive medical masks.

6. For asymptomatic individuals, wearing a mask of any type is not recommended.

7. Wearing medical masks when they are not indicated may cause unnecessary cost and a

procurement burden and create a false sense of security that can lead to the neglect of other

essential preventive measures.

Table: Guidance for use of PPE in different settings

Setting Target personnel or

patients

Activity Type of PPE or procedure

Healthcare facilities

Inpatient facilities

Patient room Healthcare personnel Providing direct care

to COVID-19 patients. Medical mask

Gown

Gloves

Eye protection (goggles

or face shield).

Aerosol-generating

procedures performed

on COVID-19

Respirator N95 or FFP2

standard, or equivalent.

Gown

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patients


patients. Gloves

Eye protection

Apron

Cleaners Entering the room of

COVID-19 patients. Medical mask

Gown

Heavy duty gloves

Eye protection (if risk

of splash from organic

material or chemicals).

Boots or closed work

shoes

Visitors Entering the room of a

COVID-19 patient Medical mask

Gown

Gloves

Other areas of

patient transit

(e.g., wards,

corridors).

All staff, including

healthcare

workers.

Any activity that does

not involve contact

with COVID-19

patients.

No PPE required

Triage Healthcare personnel Preliminary screening

not involving direct

contact (This category

includes the use of no-

touch thermometers,

thermal imaging

cameras & limited

observation &

questioning, all while

maintaining a distance

of at least 1 m.)

Maintain spatial

distance of at least 1m.

Medical Mask

Patients with

respiratory

symptoms.

Any Maintain spatial

distance of at least 1m.

Provide medical mask if

tolerated by patient.

Patients without

respiratory symptoms.

Any No PPE required

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patients


Laboratory Lab technician Manipulation of

respiratory samples. Medical mask

Gown

Gloves


of splash)

Administrative

areas

All staff, including

healthcare workers.

Administrative

tasks that do not

involve contact

with COVID-19

patients.

No PPE required

Outpatient facilities

Consultation

room

Healthcare personnel Physical examination

of patient with


Medical mask

Gown

Gloves

Eye protection

Healthcare personnel Physical examination

of patients without


PPE according to

standard precautions

and risk assessment.

Patients with respiratory

symptoms.

Any Provide medical mask.

Patients without

respiratory

symptoms.

Any No PPE required

Cleaners After and between

consultations with

patients with


Medical mask

Gown

Heavy duty gloves



material or chemicals).

Boots or closed work

shoes

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Transport teams

Ambulance or

transfer vehicle

Healthcare

personnel

Transporting suspected

COVID- 19 patients to

the referral healthcare

facility.

Medical mask

Gowns

Gloves

Eye protection

Driver Involved only in

driving the patient

with suspected

COVID-19 disease

and the driver’s

compartment is

separated from the

COVID-19patient.

Maintain spatial

distance of

atleast1m.

No PPErequired

Assisting with

loading or

unloading patient

with suspected

COVID- 19

disease.

Medical mask

Gowns Gloves Eye protection

No direct contact with

patient with suspected

COVID-19, but no

separation between

drivers’ and patients’

Compartments.

Medical mask

Patient with

suspected

COVID-19

Disease.

Transport to the

referral healthcare

facility.

Medical mask if

tolerated

Waiting room Patients with

respiratory

symptoms.

Any Provide medical mask.

Immediately move the

patient to an isolation

room or separate area

away from mothers; if

this is not feasible,

ensure spatial distance

of at least 1 m from

other patients.

Patients without

respiratory

symptoms.

Any No PPE required

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Cleaners Cleaning after and

between transports of

patients with

suspected COVID-19

disease to the referral

healthcare facility.

Medical mask

Gown

Heavy duty gloves



material or chemicals). Boots or closed

work shoes

Patients with respiratory symptoms should:

i. wear a medical mask while waiting in triage or waiting areas or during transportation within the

facility;

ii. wear a medical mask when staying in cohorting areas dedicated to suspected or confirmed cases;

iii. do not wear a medical mask when isolated in single rooms but cover mouth and nose when

coughing or sneezing with disposable paper tissues. Dispose them appropriately and perform hand

hygiene immediately afterwards.

Health care workers should:

a. wear a medical mask when entering a room where patients suspected or confirmed of being

infected with 2019-nCoV are admitted and in any situation of care provided to a suspected or

confirmed case;

b. 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

performing aerosol-generating procedures such as:

tracheal intubation

non-invasive ventilation

tracheotomy

cardiopulmonary resuscitation

manual ventilation before intubation and

bronchoscopy

Mask Management

Ifmedicalmasksareworn, appropriateuseanddisposalisessentialtoensuretheyareeffectiveandtoavoid any

increase in risk of transmission associated with the incorrect use and disposal of masks.

The following information on correct use of medical masks derives from the practices in healthcare

settings:

a. Place mask carefully to cover mouth and nose and tie securely to minimize any gaps between

the face and the mask;

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b. While in use, avoid touching the mask;

c. Remove the mask by using appropriate technique (i.e. do not touch the front but remove the

lacefrom behind);

d. After removal or whenever you inadvertently touch a used mask, clean hands by using an

alcohol- based hand rub or soap and water if visibly soiled

e. Replace masks with a new clean, dry mask as soon as they become damp/humid;

f. Do not re-use single-use masks;

g. Discard single-use masks after each use and dispose-off them immediately upon removal.

2. Additional precautions

a. Cohort HCWs to exclusively care for cases to reduce the risk of spreading transmission.

b. Place patient beds at least 1mapart;

c. Perform procedures in an adequately ventilated room; i.e. at least natural ventilation with

at least 160 l/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

d. Limit the number of persons present in the room to the absolute minimum required for

thepatient’s care and support.

e. Use either single use disposable equipment or dedicated equipment (e.g. stethoscopes,

blood pressure cuffs and thermometers). If equipment needs to be shared among patients,

clean and disinfect between each patient use (e.g. ethyl alcohol70%);

f. Refrain from touching eyes, nose or mouth with potentially contaminated hands;

g. Some aerosol generating procedures have been associated with increased risk of

transmission of coronaviruses such as tracheal intubation, non-invasive ventilation,

tracheotomy, and cardiopulmonary resuscitation, manual ventilation before intubation

andbronchoscopy. EnsurethatHCWsperformingaerosol-generatingprocedures usePPEwith

particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2 or

equivalent. When putting on a disposable particulate respirator, always perform the seal-

check. Note that if the wearer has facial hear (beard) this can prevent a proper respirator

fit.

h. Avoid the movement and transport of patients out of the room or area unless medically

necessary.

i. Use designated portable X-ray equipment and/or other important diagnostic equipment.

j. Iftransportisrequired, usepre-determinedtransportroutes tominimizeexposurestostaff,

other patients and visitors and apply medical mask to patient;

k. EnsurethatHCWswhoaretransportingpatientswearappropriatePPEasdescribedinthis

section and perform hand hygiene;

l. Notify the receiving area of necessary precautions as soon as possible before the

patient’s arrival;

m. Routinely clean and disinfect patient-contact surfaces;

n. Limit the number of HCWs, family members and visitors in contact with a patient with

suspected nCoVinfection;

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o. Maintains record ofallpersonsentering thepatient’sroomincludingallstaffandvisitors.

p. Duration of contact and droplet precautions for nCoV infection Standard precautions

should always be applied at all times. Additional contact and droplet precautions should

continue until the patient isasymptomatic.

3. Environmental Cleaning

Environmental cleaning is part of Standard Precautions, which should be applied to all patients in all

healthcare facilities

Ensure that cleaning and disinfection procedures are followed consistently and correctly. Cleaning

environmental surfaces with water and detergent and applying commonly used hospital disinfectants

(such as sodium hypochlorite) is an effective and sufficient procedure.

(Reference: Health Organization. (2019). Infection Prevention and Control during Health Care when

Novel Coronavirus (nCoV) Infection is Suspected. WHO/2019‐nCoV/IPC/v2020.1)

Cleaning agents and disinfectants

1. 1% freshly prepared Sodium Hypochlorite can be used as a disinfectant for cleaning and disinfection

2. The solution should be prepared fresh.

3. Leaving the solution for a contact time of at least 10 minutes is recommended.

4. Alcohol (e.g. isopropyl 70% or ethyl alcohol 70%) can be used to wipe down surfaces where the

use of bleach is not suitable, e.g. metals.

Personal Protective Equipment (PPE) to wear while carrying out cleaning & disinfection work

1. Wear heavy duty/disposable gloves, disposable long-sleeved gowns, eye goggles or a face shield,

and a medical mask (please see the PPE document for details)

2. Avoid touching the nose and mouth (goggles may help as they will prevent hands from touching

eyes)

3. Disposable gloves should be removed and discarded if they become soiled or damaged, and a new

pair worn

4. All other disposable PPE should be removed and discarded after cleaning activities are completed.

Eye goggles, if used, should be disinfected after each use, according to the manufacturer’s

instructions.

5. Hands should be washed with soap and water/alcohol-based hand rub immediately after each piece

of PPE is removed, following completion of cleaning

Cleaning guidelines

1. Where possible, seal off areas where the confirmed case has visited, before carrying out cleaning

and disinfection of the contaminated environmental surfaces. This is to preventunsuspecting

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persons from being exposed to those surfaces

2. When cleaning areas where a confirmed case has been, cleaning staff should be attired in suitable

PPE. Disposable gloves should be removed and discarded if they become soiled or damaged, and a

newpairworn.AllotherdisposablePPEshouldberemovedanddiscarded, after cleaning activities are

completed. Goggles, if used, should be disinfected. After each use, according to

manufacturer’sinstructions.Hands should aftereachuse, according to manufacturer’s instructions.

Hands should be washed with soap and water immediately after the PPE is removed.

3. Dedicated medical equipment/single use disposable equipment (eg; Stethoscopes, blood pressure

cuff, thermometers etc) should be used for patient care and all non-dedicated, non-disposable

medical equipment used for patient care should be cleaned and disinfected as routine disinfection

protocol (70% ethyl alcohol).

4. Mop floor with routinely available disinfectant.

5. Wipe all frequently touched areas (e.g.liftbuttons, handrails, doorknobs, armrests, tables,air/light

controls, keyboards, switches, etc.) and toilet surfaces with chemical disinfectants and allow to air

dry. 1% freshly prepared sodium hypochlorite solution can be used. Alcohol can be used for

surfaces, where the use of bleach is not suitable.

6. Clean toilets, including the toilet bowl and accessible surfaces in the toilet with disinfectant or 1%

freshly prepared sodium hypochlorite solution.

7. Wipe down all accessible surfaces of walls as well as blinds with disinfectant or bleach solution.

8. Discardcleaningitemsmadeofclothandabsorbentmaterials, e.g. Mopheadandwipingcloths, into

biohazard bags after cleaning and disinfecting each area. Wear a new pair of gloves and fasten the

double-bagged biohazard bag with a cable tie.

9. Disinfect buckets by soaking in disinfectant or bleach solution, or rinse in hot water before filling.

10. Disinfectant or 1% freshly prepared sodium hypochlorite solution should be applied to surfaces

using a damp cloth. They should not be applied to surfaces using a spray pack, as coverage is

uncertainandsprayingmaypromotetheproductionofaerosols. Thecreationofaerosolscaused by

splashing liquid during cleaning should be avoided. A steady sweeping motion should be used

when cleaning either floors or horizontal surfaces, to prevent the creation of aerosols or splashing.

Cleaningmethodsthatmightaerosolizeinfectiousmaterial,suchastheuseofcompressedair, must not be

used.

11. Biohazard bags should be properly disposed-off, upon completion of the disinfection work.

Frequency of cleaning of surfaces:

1. Hightouchsurfaces:Disinfectionofhightouchsurfaceslike(doorknobs, telephone, call bells,

bedrails, stair rails, light switches, wall areas around the toilet) should be done every 3-4hours.

2. Low-touch surfaces: For Low-touch surfaces (walls, mirrors, etc.) mopping should be done at

least once daily.

(Reference: BestPracticesforEnvironmentalCleaninginHealthcareFacilitiesinResource-Limited

Settings. CDC. November, 2019)

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Precautions to take after completing the clean-up and disinfection

1. Staff should wash their hands with soap and water immediately after removing the PPE, and when

cleaning and disinfection work is completed.

2. Discard all used PPE in a double-bagged biohazard bag, which should then be securely sealed and

labeled.

3. The staff should be aware of the symptoms, and should report to their occupational health service

if they develop symptom.

4. Bio Medical Waste Management

All articles like swab, syringes, IV set, PPE etc are to be discarded as per guidelines issued by

designated authority

All sharps like needle etc are to be collected in puncture proof container.

5. Laundry

All soiled clothing bedding and linen should be gathered without creating much motion/

fluffing.

Do not shake sheets when removing them from the bed.

Always perform hand hygiene after handling soiled laundry items

Laundry should be washed using hot water cycle. For hot-water laundry cycles, wash with detergent or

disinfectant in water at 70ºC for at least 25minutes.

6. Sample collection, storage and transportation

All specimens collected for laboratory investigations should be regarded as potentially

infectious and HCWs who collect, or transport clinical specimens should adhere rigorously to

Standard Precautions to minimize the possibility of exposure topathogens.

Ensure that HCWs who collect specimens use appropriate PPE (eye protection, medical mask,

long-sleeved gown, gloves).

If the specimen is collected under aerosol generating procedure, personnel should wear a

particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2 orequivalent

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Ensure that all personnel who transport specimens are trained in safe handling practices andspill

decontamination procedures (As per HospitalPolicy).

Samples collection:

1. Nasopharyngeal swab / NasalSwab

2. ThroatSwab

3. Before collecting the samples, it requires to be ensured that neck is in extended position.

Nasopharyngeal swab will be collected with the per nasal swab provided in the kit, after taking

out the swab it is passed along the floor of nasal cavity and left there for about five second and

transferredintoVTMand transported other designatedlabat4degreeCelsiusassoonaspossible

(sameday).

4. For collection of samples from throat area the other sterilized swab is swabbed over the tonsillar

area and posterior pharyngeal wall and finally transferred into VTM and stored and transported

to the designated lab at 4 degree Celsius as soon as possible (sameday).

Other respiratory material like endotracheal aspirated / broncheo-alveolar lavage in patientswith

more severe respiratory disease can also be collected and transported in the sameway.

5. Placespecimensfortransportinleak-proofspecimenbags/Ziplockpouch (secondarycontainer) with

the patient’s label on the specimen container (primary container), and a clearly written

laboratory requestform.

6. Ensure that health-care facility laboratories adhere to appropriate biosafety practices and

transport requirements according to the type of organism beinghandled.

7. Deliver all specimens by hand wheneverpossible.

8. Documentpatientsfullname, age/dateofbirthofsuspectednCoVofpotentialconcernclearly on the

accompanying laboratory requestform.

9. Notify the laboratory as soon as possible that the specimen is beingtransported

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Collection &Packaging of Sample (FLOWCHART)

Perform Hand hygiene

Wear appropriate PPE

Collect 2 sterile swabs –one from nasopharynx & other from oropharynx and put it into the

Labelled VTM tube.

Tighten VTM tube properly & seal it with cellotape (end of the cellotape should be double

Folded for easy opening)

Cover the VTM tube with the absorbent material (cotton/ tissue paper) & secure with rubber

band

Put it in the zip lock bag, release air from the bag and lock the bag properly. Secure the bag with

the rubber band

Disinfect the zip lock bag with 70% alcohol

Put all the samples in the vaccine carrier / thermacol box containing hard frozen gel.

Remove PPE and discard all in to yellow bag.

Perform hand hygiene

Put all requisition form in to the zip lock pouch and attach it with the inner surface of vaccine

carrier

Thermacol box /lid.

Seal the vaccine carrier / thermacol box with cellotape & disinfect with70% alcohol

Label the thermacol box/ vaccine carrier (Sender address with contact number, Recipient

Address 2019-nCoV sample, ↑ symbol.

Inform telephonically to the concerned person before sending the sample

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7. AmbulanceTransfer

When a suspect case of Coronavirus/ respiratory tract infection patient has to be transported, the

following precautions should be taken by ambulance personnel accompanying the patient:

On arrival to the healthcare facility from where the patient is to be transferred

A. Decontaminate hands (alcohol gel/rub) (Fig 1,2)

B. Don Personal Protective Equipment (PPE): (Fig3)

A patient requiring Aerosol Generating Precaution: N95 mask with respirator, gloves, long

sleeved fluid repellent gown and goggles (Annexure donning PPE)

C. Inform the hospital of the admission/transfer of a potentially infectious person

Before leaving the house/healthcare facility

Request patient to wear a surgical mask (if tolerated) and advise on Respiratory Hygiene and

Cough Etiquette

A patient with suspected or confirmed CoV should not travel with other patients

In ambulance

Remove gloves, decontaminate hands and put on new gloves before touching the patient and

before a clean or aseptic procedure, if required. Wearing gloves does not replace hand

hygiene.

Use single use or single patient use medical equipment where possible

Use disposable linen if available

Arrival to the referral hospital

Before the patient leaves the ambulance ensure arrangements are in place for receipt of

the patient

Transfer patient to the care of hospital staff

After transfer of patient remove PPE (Fig4)

Perform hand hygiene

Before ambulance is used again

Cleaning and disinfecting (PPE as outlined above should be worn while cleaning)

Surfaces (stretcher, chair, door handles etc) should be cleaned with a freshly prepared1%

hypochlorite solution orequivalent

Laundry

Place reusable blankets in a bag, then put into a laundry bag and send for laundering clearly

labeling it so that person in the laundry wears appropriate PPE before handling or autoclaves it

before opening.

Medicalequipment

Follow manufacturer’s instructions for cleaning/disinfecting reusable equipment (see guidelines)

Management ofwaste

All masks and any waste contaminated with blood or body fluid (including respiratory

secretions) should be disposed of as infectious waste in yellow bag

Management of sharps – discard in sharp container

Management of spillages of blood and body fluids – per Standard Precautions.

In the ambulance, if the driver’s chamber is not separate, driver should also usePPE

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8. Dead BodyHandling

References

Infection prevention and control during health care when novel coronavirus (nCoV)

infection is suspected Interim guidance January 2020WHO/2019-nCoV/IPC/v2020.1

CDC guidelines on PPEhttps://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdf

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https://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdf

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Rational use of PPE: According to latest guidelines on rational use of personal Protective Equipment (PPE) from

MoHFW

The PPEs are to be used based on the risk profile of the health care worker. The document

describes the PPEs to be used in different settings.

Point ofEntry-

S. No. Setting Activity Risk Recommended

PPE Remarks

1 Health Desk Provide

information to

travelers

Low risk Triple layer medical

mask

Gloves

Minimum distance

of one meter needs

to be maintained.

2 Immigration

counters,

customs and

airport security

Provide services

to the passengers


mask

Gloves

Minimum distance

of one meter needs

to be maintained.

3 Temperature

recording

station

Record

Temperature with

hand held thermal

recorder.


mask

Gloves

4 Holding area/

Isolation

facility of APHO/ PHO

Interview &

Clinical

examinationby

doctors/nurses

Moderate

Risk

N-95 masks

Gloves

5 Isolation

facility of

APHO

Clinical

management

(doctors, nurses)

Moderate

Risk

N-95 masks

Gloves

Attending to

severely ill

passenger

High risk Full complement of

PPE

When aerosol

generating

procedures are

anticipated

5 Sanitary staff Cleaning

frequently

touched surfaces/

Floor/ cleaning

linen

Moderate

risk

N-95 mask

Gloves

6 Administrative

staff

Providing

administrative

support

No risk No PPE No contact with

patients ofCOVID-

19. They should not

venture into areas

where suspect

COVID-19 cases are being managed.

2

Hospital Setting:

Out Patient Department (Respiratory Clinic / Separate screeningarea)

#

S. No Setting Activity Risk Recommended

PPE Remarks

1 Triage area Triaging patients

Provide

triple layer

mask to

patient.

Moderate

risk

N 95 mask

Gloves

Patients get masked.

2 Screening area

help desk/

Registration counter

Provide

information to

patients

Moderate

risk N-95 mask

Gloves

3 Temperature

recording

station

Record

temperature with

hand held thermal

recorder

Moderate

Risk

N 95 mask

Gloves

4 Holding area/

waiting area

Nurses /

paramedic

interacting with

patients

Moderate

Risk

N 95 mask

Gloves

Minimum distance

of one meter needs

to be maintained.

5 Doctors

chamber

Clinical

management

(doctors, nurses)

Moderate

Risk

N 95 mask

Gloves

No aerosol

generating

procedures should be allowed.

6 Sanitary staff Cleaning

frequently

touched surfaces/

Floor/ cleaning linen

Moderate

risk

N-95 mask

Gloves

7 Visitors

accompanying

young children

and elderlies

Support in

navigating various

service areas


mask

No other visitors

should be allowed to

accompany patients

in OPD settings. The

visitors thus allowed

should practice hand hygiene

All hospitals should identify a separate triage and holding area for patients with Influenza like illness. If

there is no triage area / holding area for patients due to resource constraints, such hospitals will follow

the above guidance for general OPD.

3

In-patient Services:

care management PPE activities performed.

3 ICU /critical

care

Dead body

packing


PPE

4 ICU/ Critical

care

Dead body

transport to

mortuary

Low Risk Triple Layer medical

mask

Gloves

5 Sanitation Cleaning

frequently

touched surfaces/

floor/ changing linen

Moderate

risk

N-95 mask

Gloves

6 Other Non-

COVID

treatment areas

of hospital

Attending to

infectious and

non-infectious

patients

Risk as

per

assessed

profile of

patients

PPE as per hospital

infection prevention

control practices.

No possibility of

exposure to COVID

patients. They

should not venture

intoCOVID-19 treatmentareas.

7 Caretaker

accompanying

the admitted

patient

Taking care of the

admitted patient


mask

The caretaker thus

allowed should

practice hand

hygiene, maintaina distance of 1meter

EmergencyDepartment:

S.No Setting Activity Risk Recommended

PPE Remarks

1 Emergency Attending

emergency cases

Moderate

risk

N 95 mask

Gloves

When aerosol

generating

procedures are anticipated

2 Attending to

severely ill patients of SARI


PPE

Aerosol generating

activities performed.

S. No. Setting Activity Risk Recommended PPE

Remarks

1 Individual

isolation rooms/

cohorted isolation rooms

Clinical

management

Moderate

risk

N 95 mask

Gloves

Patient masked.

Patients stable.

No aerosol

generating activity.

2 ICU/ Critical Critical care High risk Full complement of Aerosol generating

4

Pre-hospital (Ambulance) Services:


PPE

Remarks

1 Ambulance

Transfer to

designated

hospital

Transporting

patients not on

any assisted

ventilation

Moderate

risk

N-95 mask

Gloves

Management of

SARI patient

while transporting


PPE

When aerosol

generating

procedures are anticipated

Driving the

ambulance


mask Gloves

Driver helps in

shifting patients to the emergency

Other Supportive/ Ancillary Services:


Remarks

1. Laboratory Sample collection

and transportation

High risk Full complement

of PPE

Sample testing High risk Full complement

of PPE

2 Mortuary Dead body

handling

Moderate

Risk

N 95 mask

Gloves

No aerosol generating

procedures should be

allowed.

No embalming.

While performing

autopsy

High Risk Full complement

of PPE

No post-mortem

unless until specified.

3 Sanitation Cleaning

frequently

touched surfaces/

Floor/ cleaning

linen in COVID

treatmentareas

Moderate

risk N-95 mask

Gloves

4 CSSD/Laundry Handling linen of

COVID patients

Moderate

risk

N-95 mask

Gloves

5 Other

supportive

services

Administrative

Financial

Engineering

Security, etc.

No risk No PPE No possibility of

exposure to COVID

patients. They should

not venture into

COVID-19 treatment areas.

5

Health Workers in CommunitySetting

Quarantinefacility


PPE Remarks

1 Persons being

quarantined

Low Risk Triple layer mask

2 Healthcare staff

working at

quarantine

facility

Health monitoring

and temperature

recording


Gloves

Clinical

examination of

symptomatic

persons

Moderate

Risk

N-95 masks

Gloves

3 Support staff Low Risk Triple layer mask

Gloves


Remarks

1 ASHAs/

Anganwadi

and other field

staff

Field Surveillance Low Risk Triple layer mask

Gloves

Maintain distance of

one meter.

Surveillance team to

carry adequate triple

layer masks to

distribute to suspect

cases detectedon fieldsurveillance

2 Doctors at

supervisory

level

conductingfield investigation

Field surveillance

Clinical

examination.

Medium

risk

N 95 mask

Gloves.

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HomeQuarantine

P points to remember while using PPE

1. PPEs are not alternative to basic preventive public health measures such as hand hygiene,

respiratory etiquettes which must be followed at alltimes.

2. Always (if possible) maintain a distance of at least 1 meter from

contacts/suspect/confirmed COVID-19cases

3. Always follow the laid down protocol for disposing off PPEs as detailed in infection prevention and

control guideline available on website ofMoHFW.


PPE

Remarks

1 Persons being

quarantined


2 Designated

family member

Taking care of

person being

quarantined

Low Risk Gloves While cleaning

commonly touched

surfaces or handling

soiled linen

3 Other family No Risk No PPE required Maintain a distance

of at least 1 meter

from person under

home quarantine.

Senior citizens in the

household should

stay away from such

persons under home quarantine.

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Revision 1:

Guidelines for Handling, Treatment and Disposal of Waste Generated during Treatment/Diagnosis/

Quarantine of COVID-19 Patients

25th

March, 2020

(In suppression earlier guidelines upload at CPCB website on 19/03/2020)

Central Pollution Control Board

(Ministry of Environment, Forest & Climate Change) Parivesh

Bhawan, East Arjun Nagar

Delhi – 110032

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Guidelines for Handling, Treatment, and Disposal of Waste Generated during

Treatment/Diagnosis/ Quarantine of COVID-19 Patients – Rev. 1

InordertodealwithCOVID-19pandemic,StateandCentralGovernmentshaveinitiatedvarioussteps,

whichincludesettingupofquarantinecenters/camps,Isolationwards,samplecollectioncentersand

laboratories.

Following specific guidelines for management of waste generated during diagnostics and treatment of

COVID-19 suspected / confirmed patients, are required to be followed by all the stakeholders

including isolation wards, quarantine centers, sample collection centers, laboratories, ULBs and

common biomedical waste treatment and disposal facilities, in addition to existing practices under

BMW Management Rules, 2016.

TheseguidelinesarebasedoncurrentknowledgeonCOVID-19andexistingpracticesinmanagement of

infectious waste generated in hospitals while treating viral and other contagious diseases like HIV,

H1N1,etc.Theseguidelineswillbeupdatedifneedarises.ThisRevision-1ofguidelinesisdonemainlyto

incorporate specific requirements and responsibilities of persons operating quarantine camps

orcaretakers of quarantine homes/home-care units and also the responsibilities of Urban Local

Bodies(ULBs) at sections (c) and (f) respectively. Specific provisions are also incorporated for States

nothaving common CBWTFs and for allowing hazardous waste incinerators to dispose COVID-

19waste.

Guidelines brought out by WHO, MoH&FW, ICMR, CDC and other concerned agencies from time to

time may also be referred.

Guidelines for handling, treatment and disposal of COVID-19 waste at Healthcare Facilities,

Quarantine Camps/ Quarantine-homes/ Home-care, Sample Collection Centers, Laboratories,

SPCBs/PCCs, ULBs and CBWTFs is give below;

(a) COVID-19 Isolationwards:

HealthcareFacilitieshavingisolationwardsforCOVID-19patientsneedtofollowthesestepstoensure safe

handling and disposal of biomedical waste generated duringtreatment;

Keep separate color-coded bins/bags/containers in wards and maintain proper segregation of

wasteasperBMWMRules,2016asamendedandCPCBguidelinesforimplementationofBMW

ManagementRules.

As precaution double layered bags (using 2 bags) should be used for collection of waste from COVID-

19 isolation wards so as to ensure adequate strength andno-leaks;

Collect and store biomedical waste separately prior to handing over the same CBWTF. Use a dedicated

collection bin labelled as “COVID-19” to store COVID-19 waste and keep separately in temporary

storage room prior to handing over to authorized staff of CBWTF. Biomedical waste collected in such

isolation wards can also be lifted directly from ward into CBWTF collectionvan.

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In addition to mandatory labelling, bags/containers used for collecting biomedical waste from COVID-

19 wards, should be labelled as “COVID-19 Waste”. This marking would enable CBWTFs to identify

the waste easily for priority treatment and disposal immediately upon thereceipt.

General waste not having contamination should be disposed as solid waste as per SWM Rules, 2016;

Maintain separate record of waste generated from COVID-19 isolationwards

Use dedicated trolleys and collection bins in COVID-19 isolation wards. A label “COVID-19 Waste” to

be pasted on these itemsalso.

The (inner and outer) surface of containers/bins/trolleys used for storage of COVID-19 waste should be

disinfected with 1% sodium hypochlorite solutiondaily.

Report opening or operation of COVID-19 ward and COVID ICU ward to SPCBs and respective

CBWTF located in thearea.

Depute dedicated sanitation workers separately for biomedical waste and general solid waste so that

waste can be collected and transferred timely to temporary waste storagearea.

(b) Sample Collection Centers and Laboratories for COVID-19 suspectedpatients

Report opening or operation of COVID-19 sample collection centers and laboratories to concerned

SPCB. Guidelines given at section (a) for isolation wards should be applied suitably in in case of test

centers and laboratories also.

(c) Responsibilities of persons operating Quarantine Camps/Homes or Home-Carefacilities*

Less quantity of biomedical waste is expected from quarantine Camps / Quarantine Home/ Home- care

facilities. However, the persons responsible for operating quarantine camps/centers/home-care for

suspected COVID-19 persons need to follow the below mentioned steps to ensure safe handling and

disposal of waste;

General solid waste (household waste) generated from quarantine centers or camps should be handed

over to waste collector identified by Urban Local Bodies or as per the prevailing local method of

disposing general solidwaste.

Biomedical waste if any generated from quarantine centers/camps should be collected separately in

yellow colored bags (suitable for biomedical waste collection) provided by ULBs. These bags can be

placed in separate and dedicated dust-bins of appropriatesize.

Persons operating Quarantine camps/centers should call the CBWTF operator to collect

biomedicalwasteasandwhenitgetsgenerated.ContactdetailsofCBWTFswouldbeavailable with

LocalAuthorities.

Persons taking care of quarantine home / Home-care should deposit biomedical waste if any generated

from suspected or recovered COVID-19 patients, by following any of the following methods as may be

arranged byULBs;

Handovertheyellowbagscontainingbiomedicalwastetoauthorizedwastecollectorsat door steps engaged by

local bodies;or

DepositbiomedicalwasteinyellowbagsatdesignateddepositionCentersestablishedby ULBs. The bag again

be stored in yellow bag or container;or

Handover the biomedical waste to waste collector engaged by CBWTF operator at the doorstep.

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Persons operating Quarantine camps/centers or Quarantine-homes/Home-care should report to ULBs in case of any difficulty in getting the services for disposal of solid waste or biomedical waste.

Clarifications:

Quarantine Camps / Quarantine-Home / Home-care are the places where suspected people or the contacts of suspected / confirmed cases who have been directed by authorized hospitals or local authorities to stay at home for at least 14 days for observation for any symptom of COVID-19, ifany.

Patients positive for COVID-19 will not be treated at Quarantine Camps / Quarantine-Home / Home-care unless such situation is notified by the State/CentralGovernments.

Biomedical waste at Quarantine Camps / Home-care will comprise of used syringes, date expired or discarded medicines, used masks/gloves and in case of patients with otherchronic diseases may also include drain bags, urine bags, body fluid or blood-soaked tissues/cotton, empty ampulesetc.

Biomedical waste generated from Quarantine Camps / Quarantine-Home / Home-carewould be treated as ‘domestic hazardous waste’ as defined under Solid Waste Management Rules, 2016, and shall be disposed as per provisions under Biomedical Waste Management Rules, 2016 and theseguidelines.

General waste from Quarantine Camps / Quarantine-Home / Home-care shall be disposed as Solid waste as per provisions under SWM Rules,2016.

[*Amended in Rev. 1 of guidelines dated 24/03/2020]

(d) Duties of Common Biomedical Waste Treatment Facility(CBWTF):

Report to SPCBs/PCCs about receiving of waste from COVID-19 isolation wards / Quarantine Camps / Quarantined homes / COVID-19 TestingCenters;

Operator of CBWTF shall ensure regular sanitization of workers involved in handling and collection of biomedicalwaste;

Workers shall be provided with adequate PPEs including three-layer masks, splash proof aprons/gowns, nitrile gloves, gum boots and safetygoggles;

UsededicatedvehicletocollectCOVID-19wardwaste.Itisnotnecessarytoplaceseparatelabel on suchvehicles;

Vehicle should be sanitized with sodium hypochlorite or any appropriate chemical disinfectant after everytrip.

COVID-19 waste should be disposed-off immediately upon receipt atfacility.

In case it is required to treat and dispose more quantity of biomedical waste generated from COVID-19 treatment, CBWTF may operate their facilities for extra hours, by giving information toSPCBs/PCCs.

Operator of CBWTF shall maintain separate record for collection, treatment and disposal of COVID-19waste.

Do not allow any worker showing symptoms of illness to work at the facility. May provide adequate leave to such workers and by protecting theirsalary.

(e) Duties ofSPCBs/PCCs

ShallmaintainrecordsofCOVID-19treatmentwards/quarantinecenters/quarantineshomes in respectiveStates.

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Ensure proper collection and disposal of biomedical waste as per BMW Rules, 2016 and SoPS given in this guidancedocument;

Allow CBWTFs to operate for extra hours as perrequirement;

Maynotinsistonauthorizationofquarantinecampsassuchfacilitiesdoesnotqualifyashealth facilities. However, may allow CBWTFs to collect biomedical waste as and whenrequired;

In case of States not having CBWTFs as well as rural or remote areas, not having access to CBWTFs, the existing captive facilities of any hospital may be identified for disposal of COVID- 19 waste as per provisions under BMWM Rules, 2016 and theseguidelines.

Coordinate with CBWTFs and ULBs in establishing adequate collection and disposal of COVID- 19waste.

In case of generation of large volume of yellow color coded (incinerable) COVID-19 waste, permit HW incinerators at existing TSDFs to incinerate the same by ensuring separate arrangement for handling and wastefeeding.

(f) Duties of Urban Local Bodies+

Urban Local Bodies are responsible for ensuring safe collection and disposal of biomedical waste, if any, generated form Quarantine Camps/ Quarantine Homes/ Home Care for COVID-19 suspected persons.

Information on each Quarantine Camps/ Quarantine Homes/ Home-Care should be available with local administration and provide updated list to SPCBs from time totime;

In case of quarantine camps, ensure that biomedical waste is collected directly by CBWTFs identified by ULB. Waste from quarantine camps to be lifted by CBWTFs on call basis as and when the biomedical waste gets generated. Provide contact details of CBWTF operator at Quarantine Camps;

Provide necessary support, security including authorization to staff ofCBWTFs;

ULB shall engage CBWTF operator for ultimate disposal of biomedical waste collected from quarantinehome/homecareorwastedepositioncentersorfromdoorstepsasmayberequired depending on local situation; ULB shall make agreement with CBWTF in thisregard.

ULBs envisage following options to facilitate safe collection and disposal of biomedical waste from quarantined homes/Homecare;

1. Engage authorized waste collectors for door steps collection of biomedical waste and transfer to collection points for further pick-up by CBWTF;and/or

2. In case number of quarantined homes/Home-care units are less, ULBs may engage services of CBWTFs to collect the waste directly fromdoor-steps.

Provide yellow colored bags (designated for BMW) to the persons responsible for operating Quarantine Camp or home-care. If required, such bags may be provided throughCBWTF.

ULBs shall ensure the following in engaging authorized waste collectors at door-steps or at waste depositioncenters;

Createaseparateteamofworkerswhoshallbeengagedindoorstepwastecollectionat waste deposition Centre’s or at quarantine homes or homecare.

Ensure that only designated staff collects biomedical waste from quarantine homes or home care.

Training should be provided for sanitization, about collection of biomedical waste, precautionary measures to handle biomedicalwaste.

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Impart training to waste collector in handling of biomedical waste including methods of sanitization. Training to waste collectors should be arranged through CBWTFoperators;

The staff involved in handling and collection of waste from quarantine homes or home care centers shall be provided with adequate Personnel Protective Equipment such as three-layer masks, splash proof aprons/gowns, heavy-duty gloves, gum boots and safety goggles. These PPEs are required to be worn all the time while collecting of waste from quarantine center/quarantine homes/home care/waste depositionCentre’s.

Use dedicated carts / trolleys / vehicles for transport of biomedical waste. Ensure sanitization of vehicles with 1% hypochlorite after eachtrip.

Ensurethat,wastecollectorsarrivingatquarantinecenterorathomecareshallspraythe disinfectant (1% hypochlorite solution) on the bin used for yellowbag.

Establish common waste deposition centers (as stipulated under SWM Rules, 2016) for receiving / collection of biomedical waste. For this purpose, existing Dhalaos if any may be convertedsuitably.

Thegeneralsolidwastecollectedfromquarantinehomesorhomecareshallbedisposedoffas per SWM Rules,2016.

Services of Common Biomedical Waste Treatment & Disposal Facilities (CBWTFs) and staff associated with CBWTFs for collection, transportation, treatment and disposal of biomedical waste generated from hospitals including COVID-19 isolation wards, Quarantine Camps, etc. may be considered an essential service as part of healthinfrastructure.

Facilitate smooth operations ofCBWTFs.

References Infection prevention and control during health care when novel coronavirus (nCoV) infection is

suspected Interim guidance January 2020 WHO/2019- nCoV/IPC/v2020.1

CDC guidelines on PPEhttps://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdf

AIIMS -Infection Prevention & Control Guidelines for 2019-nCoV (COVID-19).

MOHFW guidelines –advisory on dead body management.

These guidelines will be changed as and when new guidelines issued by MoHFW.

https://www.cdc.gov/HAI/pdfs/ppe/PPEslides6-29-04.pdf

Annexure 1”

ABVIMS & DR RAM MANOHAR LOHIA

HOSPITAL NEW DELHI- 110001

SELF DECLARATION FORM

Name: Date:

Age/Sex: Address:

Phone Numbers:

Office:

Residence:

Mobile:

SYMPTOMS

Fever:

Sore throat /Cough:

Running / Blockednose:

Breathlessness:

Others:

H/O Travel Abroad:

H/O Contact with a confirmed case:

Details of confirmed Case:

H/O close contacts with Name, Address & Phone nos.

Signature of Patient / Guardian

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