Clinical Management

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Preparing your hospital

Introduction / overview

Because COVID-19 is highly infectious, facility preparedness and management is critical to assure high quality care for patients who are sick with COVID-19, and to protect staff and non-COVID-19 patients from contracting coronavirus. Like the management of Ebola, Lassa, cholera or other infectious diseases, infection control and prevention (IPAC) is central to facility management.

IPAC requires the right staffing, stuff (supplies like PPE), space (for proper distancing and triage) and systems (to assure adherence to IPAC protocols). This section describes the preparation and management of a facility for COVID-19 patients.

Clinic and hospital outpatient areas

Triage at designated points of entry

  • Points of entry should be limited
  • Initial screening: Triage in open air, e.g. as vehicles pull up or on walkway outside. Health workers in PPE, screening of patients for symptoms and contact or travel history
  • Patients who are positive for symptoms, contact or travel are considered to be suspected or probable cases; they should be given a mask and told to go to the waiting area to wash hands and wait 2 m from the nearest patient. Patients negative for symptoms, contacts or travel should go to the hand-washing station nearest to the facility and then proceed to inpatient or outpatient triage area

Waiting area for probable cases

  • Patients have masks
  • Will have washed hands before entry
  • Will sit >2 m from other patients with physical barriers between. Area is preferably open to the air on all three sides

Consultative space

Contiguous with waiting area and separate from other areas of the facility.

  • Separate entrance for healthcare workers
  • Healthcare workers in PPE

Specimen collection space

  • Sputum collection should be done outside in an area designated for sample collection
  • Nasal and pharyngeal swabs, blood finger prick and blood draws can be done in the consultative space

Hospital (or clinic) inpatient areas

Isolation room / isolation ward

Negative pressure rooms should be used whenever possible. COVID-19 patients should be cared for in single self-contained isolation rooms or on wards with other confirmed COVID-19 patients; all patients’ beds should be placed at least 1 metre apart. Where negative pressure is not available, patients should be placed in adequately ventilated rooms, considered to be 60 L/s per patient.

For COVID-19, infrastructure (spaces) should include:

  • Screening tent: At entrance of hospital to screen all patients with temperature and basic symptoms
  • Triage unit: For patients who meet case definition at triage, and require COVID-19 lab testing
  • Suspected/probable case ward: For patients considered suspected or probable cases for COVID-19 to get care for respiratory illness, while awaiting COVID-19 testing. Notably, this ward requires the highest level of IPAC, to reduce nosocomial transmission, as patients here are a mix of positive/negative
  • COVID-19 inpatient ward(s): For care of stable patients with confirmed or highly suspected COVID-19 (known contact, ARDS)
  • COVID-19 ICU: For care of critically ill patients
  • Small laboratory space: For running COVID-19 test
  • Donning stations: Separate from areas with suspected/probable cases or COVID-19 positive patients where health personnel can put on protective gear
  • Doffing stations: For each area where used material will either be sterilised (bucket for goggles), incinerated, or laundered and handled by cleaning personnel in full PPE
  • Patient exit
  • Laundry

Infrastructure and facility standards

Facility NeedsCOVID-19 Treatment Centre Standards

Water supply
1. Supply
2. Potability

3. Reserve capacity
4. Redundancy
5. Access points

Adequate water supply is required for hand washing, drinking water for patients, staff, and family caregivers, cleaning, patient bathing on discharge. This includes water for laundry

Power supply
1. Reliability
2. Capacity
3. Redundancy

4. Controls

Consistent electrical power is needed for safe basic care. For non-ICU level care, two sources of electricity are needed. They can be any combination of diesel generator, solar and batteries, or utility grid connection. In the case of generator only, two redundant generators are recommended

Whatever the energy sources are, there should be an automatic transfer switch between the two primary sources of power. If there is an ICU, there should be a Universal Power Supply (UPS) installed to feed the receptacles for lights and power of at least 20 kVA. Main circuit breaker and electrical panel should be readily accessible but located outside of patient areas so that a technician can service without PPE

Automatic transfer switch and saddle tank for generators should be provided. Saddle tank should be sized to provide fuel for a minimum of seven days continuous generator use

Power distribution & lighting
1. Ward level
2. Distribution level
3. Documentation

Treatment and administrative areas need minimum of 40 foot- candles of illumination at 1 metre above the floor. All lighting should be LED strip lighting securely hung on chain or wire at a minimum of 2.6 m above the floor. All treatment areas should have a minimum of two duplex receptacles for each bed or patient exam chair. There should be no more than five duplex receptacles on each 20 amp circuit breaker. For ICU, there should be three dedicated 20 amp duplex receptacles for each bed all fed from a UPS

Wastewater treatment
1. Treatment level
2. Capacity
3. Monitoring and maintenance

Wastewater from hand sinks, janitorial sinks, and showers should be discharged by gravity into holding tank for 48-hour retention and chlorination and then discharged into soak pit, built to WHO and MSF guidelines

Toilets in temporary facilities should be dedicated pit latrines which discharge into a lined tight tank of sufficient size that requires pumping no more than twice per month. The lined pit latrine should have access and inspection hatches and vented to promote breakdown of solids to the WHO guidelines for “Improved Pit Latrines”. There should be an overflow pipe for liquid wastewater at least 15 cm below the floor and run to a separate soak pit

Biohazard, pharma, and chemical waste
1. Collection/sorting
2. Disposal
3. Staff safety

Sharps containers should be mounted at between 1.3-1.4 metres above the floor. The container should be placed in a visible location, within easy horizontal reach, and below eye level. The container should also be placed away from any obstructed areas, such as near doors, under sinks, near light switches, etc. Containers should be clearly visible to the health care worker. There should be one 5 L sharps container for every 4 beds or patient exam stations, and no less than 1 sharps container per room

1. Supply
2. Distribution

3. Reserve capacity
4. Redundancy

An oxygen quantity of 10 L per minute (LPM) per bed is recommended for sizing piped oxygen planning. RESERVE oxygen is required as well as REDUNDANT CAPACITY if supply fails. If a manifold with high pressure oxygen cylinders is used, then there should be an adequate supply for all the beds for 24 hours of use at 6 LPM. In a 16-bed ward this would translate to 96 LPM. A 75% diversity factor then can be applied so the 24-hour supply would be 96 LPM x 60 Min *.75= 4320 LPM. An H-cylinder yields approximately 7,000 usable litres; so, for a 24 hour supply you would need 15 full cylinders. A reserve manifold (in addition to the 15 cylinders) should have a minimum of 4 full H-cylinders. The manifold and zone valve must be connected to an audible and (if possible) visual alarm to notify if there is a drop in oxygen pressure below 40 PSI. Ideally, there should be redundancy in oxygen. Bedside oxygen concentrators are a good option. Anticipate that up to 40% of patients with COVID-19 will require oxygen
Either mechanical ventilation through the use of exterior exhaust fans and opposite wall/end air intake louvers to achieve 12 air changes/hour (ACH) by volume in the space. It may be possible in some locations and climates to achieve 12 ACH by using natural ventilation, especially a scheme that utilizes low intake and high exhaust. If this method is employed, it is strongly recommended that a professional engineer be consulted and that the space be tested for CO2 build up and transfer prior to the space being operationalized

Network/internet connectivity
1. Reliability
2. Speed

3. Availability

Ability to connect to the internet whether via wire or wireless connection wherever layout of facility deems necessary. Suggest: Dual Wired RJ45 connections at each convenient and/or required location

Wireless Access Points placed throughout facility positioned for complete and optimum coverage

Consider backup internet source from 4G cellular routers, if available

Fire safety
1. Fire extinguisher
2. Smoke detectors
3. Fire assembly points
4. Fire evacuation plan

Fire safety in temporary facilities in countries with little or no fire safety training and standards is always challenging. We suggest a flexible commonsense approach. Within the temporary wards, try to avoid using sheets or other linens for shading as these are an obvious fire hazard. Fire extinguishers should be employed and hung on the walls in locations that are accessible and highly visible. We recommend a minimum of two per every 1000 square feet, plus one by each exit and entrance. There should be fire extinguishers not more than 50 feet (or 15 m) apart throughout the facility. The fire extinguishers should be clearly marked with a sign and arrow in the appropriate language
Table from PIH

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