COVID- 19- Policies and Procedures

Hospital Infection control Policy

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

Prepared and approved by: Hospital Infection Control Committee
Date: 22/03/2020


Coronaviruses (CoV) belong to a family of viruses that cause illness ranging from the common cold to more severe diseases. A novel coronavirus (2019-nCoV) is a new strain that has not been previously identified in humans. The infection is spread through respiratory route i.e. respiratory droplets and direct human contact. Healthcare personnel (HCP) are at risk of infection through respiratory routes and direct contact with infectious patients.
In view the current situation regarding COVID -19 disease in India, we need to be prepared for the handling of suspect and confirmed cases, who might present to the hospital.
These guidelines are supplementary to the existing Hospital Infection control Manual of our hospital. The guidelines have been adapted from the existing WHO & CDC recommendations. Standard recommendations to prevent infection spread include standard precautions, contact precautions and respiratory precautions. Patients suspected of having 2019-nCoV infection should be shifted to the isolation facility/ refereed to MCH from the triage area as soon as possible. The HCP should do this after donning appropriate PPE. The suspected patient should wear mask/respirator.
Standard precautions
Health-care workers caring for PUI (Patient under investigation) patients should implement standard infection control precautions. These include basic hand hygiene, use of personal protective equipment, respiratory etiquettes, and environmental disinfection.
Patient placement 

The PUI has to be admitted in an isolation room with negative pressure ventilation.
• Only essential personnel should enter the room.
• Implement staffing policies to minimize the number of HCP who enter the room.
• Facilities should keep a log of all persons who care for or enter the rooms or care area of these patients.
• Use dedicated or disposable noncritical patient-care equipment (e.g., blood pressure cuffs). If equipment will be used for more than one patient, clean and disinfect such equipment before use on another patient according to manufacturer’s instructions.
• HCP entering the room soon after a patient vacates the room should use respiratory protection.
General Guidelines to be followed at each Department:
1. Single point of entry to practiced to the hospital through emergency department. Security supervisor must ensure that the persons entering in to the hospital are properly washed their hands.
2. Security must allow only attender along with patient.
3. Minimize the patient waiting time at every point of service
4. Single window policy to be followed at reception (each counter must follow multiple task like OP registration, IP registration etc.)
5. Special consideration to be given to vulnerable group.
6. Any patient who comes from foreign country should visit the OPD through Counter number 5. Such data should be specially noted and handed over to health department.
7. All employees should wear three layered mask
8. Reception staff must were gloves while on duty.
9. Avoid prior booking and appointments. Service should strictly based on first come first serve.
10. At least one meter distance to be maintained at all point of service
11. Hospital Supervisor should ensure that there is no delay in serving patients.
12. Hand sanitizer must be placed at the entrance of all OPDs and OPD assistance should provide it to patient/ attender at the time of OPD visit.
13. Only one attender is allowed to enter the OPDs
14. Mask should make available at the pharmacy to serve the patient/ attender at a reasonable cost.
15. Patient/ attender should sit at distance of one hand in waiting area. (Alternative chairs).
16. Practice of hand washing and use of alcohol based hand rub to be strengthened all point of care. Store in charge should be more conscious in arranging adequate stock of these items.

Advice on the usage of PPE in the context of COVID-19
The following are recommendations for the rational use of personal protective equipment (PPE) at health care facilities. PPE includes gloves, medical masks, goggles or a face shield, and gowns, as well as for specific procedures, respirators (i.e., N95) and aprons. It is intended for HCPs, infection prevention and control (IPC) professionals and health care managers.
General Advice
Hand hygiene remains one of the most important measures for all persons for the prevention and control of majority of the respiratory viral infections -, including 2019-nCoV infections or COVID-19. This can be performed with soap and water or alcohol-based hand rubs. Wearing a medical mask is one of the prevention measures to limit spread of certain respiratory diseases, including 2019-nCoV, is useful when worn by the persons suffering from the disease or contacts of the patients. These measures must be combined with other IPC measures to prevent the human-to-human transmission of COVID-19, depending on the specific situation.
Community setting (Applicable to all staff)
Individuals without respiratory symptoms should:
i. avoid agglomerations and frequency of closed crowded spaces;
ii. maintain distance of at least 1 meter from any individual with 2019-nCoV respiratory symptoms (e.g., coughing, sneezing);
iii. perform hand hygiene frequently, using alcohol-based hand rub if hands are not visibly soiled or soap and water when hands are visibly soiled;
iv. if coughing or sneezing, cover nose and mouth with flexed elbow or paper tissue, dispose-off tissue immediately after use and perform hand hygiene;
v. refrain from touching mouth and nose; vi. a medical mask is not required, as no evidence is available on its usefulness to protect non-sick persons. However, masks might be worn according to local cultural habits. If masks are used, best practices should be followed on how to wear, remove, and dispose of them and on hand hygiene action after removal (see below advice regarding appropriate mask management).

Individuals with respiratory symptoms should:
i. wear a medical mask and seek medical care if experiencing fever, cough and difficulty breathing, as soon as possible or in accordance with to local protocols;
ii. Follow the below advice regarding appropriate mask management.
Health Care Facilities
Individuals 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 like bronchoscopy, CPR, mechanical ventilation etc.
Masks management
If medical masks are worn, appropriate use and disposal is essential to ensure they are effective and to avoid 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 minimise any gaps between the face and the mask;
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 lace from 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.

Decontamination and Waste Management
• In addition to using the appropriate PPE, frequent hand hygiene and respiratory hygiene should always be performed. PPE should be discarded in an appropriate waste container after use, and hand hygiene should be performed before putting on and after taking off PPE.
• Any surface or material known to be, or potentially be, contaminated by biological agents during laboratory operations must be correctly disinfected to control infectious risks. Proper processes for the identification and segregation of contaminated materials must be adopted before decontamination and/or disposal.
• Where decontamination cannot be performed in the laboratory area or onsite, the contaminated waste must be packaged in an approved (that is, leakproof) manner, for transfer to another facility with decontamination capacity.
Donning (putting on) PPE:
These requirements apply to all staff entering the room of a corona virus infected patient. The following PPE is required to be donned prior to entry into the patient room. Donning in the following order is recommended.
1. Gown
A clean, nonsterile, disposable, isolation gown must be worn. Ensure that gown is tied in back and provides full coverage.
2. N-95 respirator
a. All staff must wear approved respiratory protection (N-95 respirator).
b. Before using an N-95 respirator, staff must be medically cleared and trained in how to wear/use each device.
c. For N-95 respirators, staff must have been fit-tested within the past year to ensure proper size and fit.
d. A “fit-check” (also known as a “seal check”) should be performed before each N-95 respirator use.
e. The N-95 respirator must be discarded after each use.

2. Goggles/Face shield
All staff must wear goggles or face shield to protect mucous membranes from exposure due to splash or potential for hand contamination of eyes, nose or mouth.
3. Gloves
All staff must wear clean, nonsterile gloves. Gloves must be pulled over the sleeves/cuffs of gown.

Practices for Environmental Cleaning in Healthcare Facilities
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.
Cleaning agents and disinfectants
1. 1% 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.
Frequency of cleaning of surfaces:
1. High touch surfaces: Disinfection of high touch surfaces like (doorknobs, telephone, call bells, bedrails, stair rails, light switches, wall areas around the toilet) should be done every 3-4 hours.
2. Low-touch surfaces: For Low-touch surfaces (walls, mirrors, etc.) mopping should be done at least once daily.
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 prevent unsuspecting 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 new pair worn. All other disposable PPE should be removed and discarded, after cleaning activities are completed. Goggles, if used, should be disinfected after each use, according to manufacturer’s instructions. Hands should be washed with soap and water immediately after the PPE is removed.
3. Mop floor with routinely available disinfectant.
4. Wipe all frequently touched areas (e.g. lift buttons, hand rails, doorknobs, arm rests, tables, air/ light controls, keyboards, switches, etc.) and toilet surfaces with chemical disinfectants and allow to air dry. 1% sodium hypochlorite solution can be used. Alcohol can be used for surfaces, where the use of bleach is not suitable.
5. Clean toilets, including the toilet bowl and accessible surfaces in the toilet with disinfectant or 1% sodium hypochlorite solution.
6. Wipe down all accessible surfaces of walls as well as blinds with disinfectant or bleach solution.
7. Remove curtains/ fabrics/ quilts for washing, preferably using the hot water cycle. For hot-water laundry cycles, wash with detergent or disinfectant in water at 70ºC for at least 25 minutes.
8. Discard cleaning items made of cloth and absorbent materials, e.g. mop head and wiping cloths, 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% 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 uncertain and spraying may promote the production of aerosols. The creation of aerosols caused 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. Cleaning methods that might aerosolize infectious material, such as the use of compressed air, must not be used.
11. Biohazard bags should be properly disposed-off, upon completion of the disinfection work.
Precautions to take after completing the clean-up and disinfection
12. Staff should wash their hands with soap and water immediately after removing the PPE, and when cleaning and disinfection work is completed.
13. Discard all used PPE in a double-bagged biohazard bag, which should then be securely sealed and labelled.
14. The staff should be aware of the symptoms, and should report to their occupational health service if they develop symptoms.
Table 1: Guidance for use of PPE in different settings
Setting Target personnel or patients Activity Type of PPE or procedure
Health care 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 Patients • Respirator N95 or FFP2 standard, or equivalent.
• Gown
• 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 COVID -19 patients • Medical mask
• Gown
• Gloves
Laboratory Lab technician Manipulation of respiratory samples. • Medical mask
• Gown
• Gloves
• Eye protection
Administration All staff, including healthcare workers Administrative tasks that do not involve contact with COVID-19 patients. • No PPE required
Outpatient care
Consultation room Healthcare personnel Physical examination of patient with or without respiratory symptoms. • Medical mask
• Gown
• Gloves
• Eye protection
Waiting room Patients with or with out respiratory symptoms Any • Provide medical mask.
• Ensure spatial distance of at least 1 m from other patients.


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