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Clinical management of COVID-19

This website is intended as a resource for healthcare professionals dealing with the COVID-19 pandemic.

Our team of medical professionals from the Inspiral Health team are continually adding new content with the aim of helping fellow healthcare professionals around the world access best-of medical information about COVID-19.

If you would like to contribute information to this site, or see any errors or have any comments, then please contact us.

Thank you for taking the time to visit this website.

Testing for COVID-19

COVID-19 is highly infectious. Infection control and prevention (IPAC) are critical to protect patients and staff. Administrative controls, environmental controls and personal protection are all key elements of a safe environment. All of these controls rely on vigilance for suspected cases and safe screening, testing and isolating confirmed cases.

Screening, triage & testing, isolation

A. Initial screening

  • Separate screening area outside of health care facility or at hospital entrance
  • All patients entering healthcare facility are screened for fever, cough, SOB, known contact of COVID-19 patient, or recent travel that may place them at risk. Screener should wear full PPE
  • If initial screen positive:
    • Immediately place face mask on patient and provide patient with alcohol based hand sanitizer
    • Direct patient to triage & testing area

B. Triage & testing

  • Secondary screening space should be separated from other patients
  • Providers should don full PPE and observe contact and droplet precautions
  • Follow protocols for specimen collection for laboratory testing
  • Asymptomatic patients may be directed home with follow up and to self- quarantine pending test results
  • Symptomatic patients will be admitted to isolation area per protocol

C. Probable or suspected cases of COVID-19:

There should be separate isolation areas for probable or suspected cases who have not been confirmed to have COVID-19.

  • When a patient comes to a facility with symptoms consistent with COVID-19 or known contact with COVID-19, it is important that IPAC is adhered to. There are three levels of isolation:
    • Asymptomatic: Known contact, but not displaying symptoms. Once tested asymptomatic patients may return home with close follow up and instructions to self-quarantine pending test results
    • Symptomatic: Should be evaluated clinically for admission and separated from asymptomatic suspects pending the test result
    • Presumptive case areas for asymptomatic or symptomatic suspected cases should be separated into low and high risk sides depending on clinical suspicion

D. Isolation for confirmed positive patients OR highly symptomatic probable cases

(Especially with a close family contact with a symptomatic or confirmed case): Should be separated from suspected cases and moved immediately to the isolation unit.

E. General practices and procedures

  • Providers should complete their patient assessments moving from asymptomatic to symptomatic patients and finally to confirmed patients
  • Limit transport and movement of patients. When transport is necessary don clean PPE, place face mask on patient, and follow respiratory/hygiene etiquette
  • The isolation areas must be separate enclosed spaces removed from other patients
  • Equipment (stethoscope, BP cuff, pulse oximeter) must remain in the room and must be cleaned and disinfected between each patient (e.g., by using ethyl alcohol 70%)
  • No visitors for suspected or confirmed patients (see exceptions below) as a strategy to help conserve PPE. All parents must wear PPE and can remain with a child as a caregiver
  • Once patient is in the isolation area they cannot leave except to a dedicated bathroom for isolated patients, movement within the hospital per healthcare provider, or discharge
  • Maintain a record of all persons entering a patient’s room or isolation space, including all staff and visitors

What should I do if I suspect a patient may have COVID-19?

How to identify potential new cases of COVID-19 and either isolate patients to reduce transmission, or refer safely to the hospital if severely unwell.


This graphic is based on guidance from Public Health England and Health Protection Scotland to prepare primary care practices in the UK. It has been updated to reflect new UK government advice to the public announced on 16 March 2020

What is a Pandemic and How to initially deal with a Pandemic – this is how …

Dominic Morgan, Director of Operations for the UK Charity Inspiral Health explains ‘What is a Pandemic’ and ‘How to initially deal with a Pandemic’ …

How to initially deal with a Pandemic

Dominic Morgan explains how to initially deal with a pandemic

What is COVID-19 ?

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus.

Most people infected with the COVID-19 virus will experience mild to moderate respiratory illness and recover without requiring special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness.

The best way to prevent and slow down transmission is to be well informed about the COVID-19 virus, the disease it causes and how it spreads. Protect yourself and others from infection by washing your hands or using an alcohol based hand rub frequently and not touching your face. 

The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes, so it’s important that you also practice respiratory etiquette (for example, by coughing into a flexed elbow).

At this time, there are no specific vaccines or treatments for COVID-19. However, there are many ongoing clinical trials evaluating potential treatments.

How is SARS-CoV-2 (COVID-19) different from MERS or SARS-CoV-1

All three of them are what are called zoonotic diseases. So these are coronaviruses that don’t normally circulate in humans, they normally circulate in other animal species.

In this case many of them seem to be similar to bat coronaviruses at least in the case of the novel 2019 coronavirus. And then they jump into humans and cause an unusual syndrome because the human body isn’t used to interacting with that virus.

In terms of how they’re different from SARS and MERS: the mortality difference seems to be quite striking. SARS had a mortality on average in the 10 to 12 percent range overall, whereas this novel coronavirus has a mortality that’s closer to 2%. MERS was closer to 30% mortality.

Other big differences SARS seem to affect healthcare providers and really had an affinity for hospitals, whereas the novel coronavirus, there has been very limited transmission and examples published to healthcare workers it seems to not have a preponderance to circulating in healthcare, although we’re still waiting for more data on that.

How COVID-19 spreads & how to avoid passing it on

Strategic Incident Director for COVID-19 Professor Keith Willett explains how someone can catch coronavirus, how it spreads and how you can avoid passing it on.

Hello I’m Professor Keith Willett — I’m the Strategic Incident Director for Coronavirus for the NHS.

It’s important we understand what coronavirus is, and how a virus causes infection and that means it’s much easier for us to understand how we should behave at home, and at work.

So a virus is a tiny, tiny piece of genetic material. On your hands you know that you have millions of bacteria, but you can’t see them. If I was a bacteria, a virus to me would be no more than a mosquito on my skin. The way a virus gets into your body and causes illness is it comes in onto your moist surfaces — your nose, your mouth, your throat — it attaches to those cells, gets into the cell, and basically takes over the production line of your cell — producing tens of thousands of viruses.

The cell then breaks down, your body reacts for the first time by giving you a temperature and a fever because you’re now fighting something, and at the same time as the virus is emitted from that cell you start to cough. That’s the first time you really become infectious. So for the five days before you’re probably not infectious. But it’s important then if someone has coronavirus and they start coughing, that they catch it in a tissue and bin it.

The other way you catch coronavirus is from surfaces. Surfaces that someone has touched. So it’s important that whenever someone has coronavirus that their surfaces around them are regularly cleaned — the door handles, the toilet, you don’t share things like towels.

When someone is coughing the virus needs to move on to somebody else. It can’t get there without a vehicle. The vehicle it uses are the heavy droplets that you cough, and they are only shed a few feet away from the individual. So if you’re two meters away — social distancing — you won’t catch the virus. If you’re close to them, and you’re at work, you need to be wearing protective equipment.

At home you need to keep the distance. That’s how the virus moves around our society. If you can avoid those risks of transmission of the virus, it will all help us in the NHS. Do take care.

What is Integrated Crisis Management (ICM)

My name is Dominic Morgan and I am the Director of Operations for Inspiral Health.

Inspiral Health is a ‘coalition of the willing’, being built by global clinicians, educational and industry leaders and experience disaster responders. All volunteers to bring together their individual knowledge and desire into a collective effort, to help build a better reality for all. 

A crisis can be defined as a critical event or sequence of unstable, dangerous critical events capable of overwhelming current organisational structures, capacity, and response, or to cause, by its very nature a loss of structures, capacity, and response, directly leading to suffering or organisational loss.

When faced with crisis, which by its very definition has the potential to either overwhelm us and our organisations, or to adversely impact on us or organisational resources, such as a pandemic or Sudden Impact Disaster (SID), causing both impacts to occur at the same time. Therefore, in crisis, we are required to think and act differently. So how do we do this. 

The answer is amazingly simple, as a crisis affecting a complex environment, cannot be resolve with a complicated solution. Consider this equation, if you have a complex environment, such as health care, any solution that is complicated will normally result in unachievable. Therefore, if something is unachievable, in any circumstances, it often means you have complication and complexity working against each other. Crisis cannot be solved this way.

Complicated + Complexity = Unachievable.

Equally, Unachievable = Complicated + Complexity.

Integrated Crisis Management (ICM) is designed to apply a clear and simple response to all crisis situations and while ICM preparation will reduce the scale and nature of the adverse impact created by crisis, it can also be applied during any crisis.

So how do we respond to crisis and what is Integrated Crisis Management or ICM, as it’s known? ICM has been developed in response to address significant crisis, that could be affecting you, your family, your team, your organisation, your healthcare system, county or a global need or threat. It can address all crisis situations, affecting any type of organisation, at any time.

Integrated Crisis Management: Where does it come from?

So where does Integrated Crisis Management (ICM) come from?

ICM has been developed from two well understood major incident response structures. The first is Integrated Emergency Management (IEM), developed in the UK for major incident management, in the 1980’s. Developed to address shortcomings identified after numerous Major Incident response failures.

It was recognised that organisations responding to significant major incidents was being adversely affected by each responding organisation having its own organisational priority, such as police, fire, ambulance and others such the military, coast guard, Royal National Lifeboat Institution (RNLI) or any responding agency depending on the type of major incident. While each organisational priority was valid, it was recognised time and time again in major incident debriefs that this did not create the right environment to create an integrated major incident response.

Most recent examples of this failure would include the Manchester bombing, where one agency adversely affected the overall outcome, by restricting medical aid to the victims. IEM requires each responding agency to come together at the earliest practical point in a major, in a process labelled as ‘over the bonnet’. This label describes exactly the requirement to find the nearest vehicle, to get the bonnet and agreed on an integrated operational plan, in the now, using the actual available resources.  Not the resources you would like but the actual resources you have and can realistically rely on. 

ICM is also underpinned by the Incident Command System or ICS as its known. ICS was developed in the late 1960’s and 1970’s in North America after several wildfires, leading to significant loss of life and property. Following incident reviews, it was established that response problems often related to communication and management deficiencies rather than lack of resources or tactical failure. ICS was developed to address these failings and was collaboratively developed to provide a consistent, integrated framework for the management of all incidents from small incidents to large, multi-agency emergencies, by providing clear command and control, response structures, accountability and major incident roles, that could be pre-trained across all responding organisations. ICS is the standard major incident response system globally.

Integrated Crisis Management – How to apply it?

As explained ICM is remarkably simple, as simplicity is the only effective way to respond to crisis. Introducing further complication to the complex environment of a crisis simply does not work.

Think of it like this; as you walk into your kitchen tonight to make yourself a pizza, you discover that you cannot, due to several reasons. There is no flour, or the cooker no longer works, it could be that bugs have eaten your flour, or the cooker is broken, or the gas is not flowing. It really does not matter what the cause is, as your pizza plans are now in crisis. 

At this point you can apply ICM following the 8 R’s method. So, what are the 8 R’s?

  1. Redefine (Question the question). What is your aim, is it to make a pizza or just to get some nourishment?
  2. Reprioritise (Set new goals). Having decided your aim, reprioritise your objectives to meet your aim.
  3. Remove (Stop doing the unnecessary). What do you need to achieve now, to meet your new aim? Remove, delay or cease doing anything that can you affect your resources, structures or effort.
  4. Repurpose (Bring together what you have). Being clear what your aim is now requires you to identify the true resources you have into one response.
  5. Respond (Act, crisis will not wait for you). Having recognised the need to repurpose to achieve your new aim, you now need to act to match the event pace and to get in front of the adverse impact being created by crisis. 
  6. Re-energise (Visualise success). Clearly visualise what success looks like to your patients, you, your family, your team, your organisation, your county and globally and build support to achieve your success. No decision in isolation
  7. Review (Constant checking). Always review your aims, goals, objectives, resources and drive to achieve your new response. 
  8. Repeat (Start back at the question). Follow the process again to ensure you remain on track to deliver your aims, goals, objectives and that you have the resources to deliver. this should be repeated depending on the crisis need.  

Constantly ask yourself this question;

“Have your aims failed due to the lack of effort or to lack of understanding of the challenge?”

Repeated crisis strategic, tactical and operational failures can be shown to be created through a lack of true understanding of the challenge.

Common COVID-19 symptoms

COVID-19 affects different people in different ways. Most infected people will develop mild to moderate illness and recover without hospitalisation.

Most common symptoms

  • Fever
  • Dry cough
  • Tiredness

Less common symptoms

  • Aches and pains
  • Sore throat
  • Diarrhoea
  • Conjunctivitis
  • Headache
  • Loss of taste or smell
  • A rash on skin, or discolouration of fingers or toes

Serious symptoms

  • Difficulty breathing or shortness of breath
  • Chest pain or pressure
  • Loss of speech or movement

Seek immediate medical attention if you have serious symptoms. Always call before visiting your doctor or health facility. 

People with mild symptoms who are otherwise healthy should manage their symptoms at home. 

On average it takes 5–6 days from when someone is infected with the virus for symptoms to show, however it can take up to 14 days. 

Sources & links

COVID-19 danger signs

Look for emergency warning signs for COVID-19. If someone is showing any of these signs, seek emergency medical care immediately:.

  • Trouble breathing
  • Persistent pain or pressure in the chest
  • New confusion
  • Inability to wake or stay awake
  • Bluish lips or face

Know the symptoms of COVID-19, which can include the following:







muscle ache




sore throat


new loss of taste and smell


NOTE: This list is not exhaustive, also see this post on COVID-19 symptoms.

Symptoms can range from mild to severe illness, and appear 2-14 days after you are exposed to the virus that causes COVID-19.

Sources & links

  • CDC | Illustrations used on this page | Link
  • webmd | Warning signs | Link

Personal Protective Equipment (PPE)

Introduction / overview

Access to adequate quantities and types of personal protective equipment (PPE) is an essential component of providing safe clinical care during the COVID-19 pandemic – essential for protecting yourself, your staff and your patients. This page lists the necessary equipment for implementing contact/droplet precautions in your healthcare facility.

Equipment needed

Eye and face protection

Eye and face protection provides protection against contamination to the eyes from respiratory droplets, aerosols arising from AGMPs and from splashing of secretions (including respiratory secretions), blood, or other bodily fluids.

Eye and face protection can be achieved by the use of any one of the following:

  • Surgical mask with integrated visor
  • Full face shield or visor
  • Polycarbonate safety spectacles or equivalent

Regular corrective spectacles are not considered adequate eye protection.

While performing AGMPs, a full face shield or visor is recommended.

The same as for respirators and FRSMs, eye protection should: be well fitted; not be allowed to dangle after or between each use; not be touched once put on; be removed outside the patient room, cohort area or 2 metres away from possible or confirmed COVID-19 cases.

Disposable, single-use, eye and face protection is recommended for single or single session use and then is to be discarded as healthcare (clinical) waste. However, re-usable eye and face protection is acceptable if decontaminated between single or single session use, according to the manufacturer’s instructions or local infection control policy.


It is important that the eye protection maintains its fit and function and remains tolerable for the user. Eye and face protection should be discarded and replaced and not be subject to continued use if damaged, soiled (for example, with bodily fluids) or uncomfortable.


Respirators are used to prevent inhalation of small airborne particles arising from AGMPs. All respirators should:

  • Be well fitted, covering both nose and mouth
  • Not be allowed to dangle around the neck of the wearer after or between each use
  • Not be touched once put on
  • Be removed outside the patient room, cohort area or COVID-19 ward

Respirators can be single use or single session use (disposable) and fluid-resistant. Note that valved respirators are not fully fluid-resistant unless they are also ‘shrouded’. Valved, non-shrouded FFP3 respirators are not considered to be fluid resistant and therefore should be worn with a full face shield if splashing of blood or bodily fluids is anticipated.

FFP3 respirators filter at least 99% of airborne particles. The HSE states that all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to ensure an adequate seal or fit (according to the manufacturers’ guidance). Fit checking (according to the manufacturers’ guidance) is necessary when a respirator is donned to ensure an adequate seal has been achieved.


Fit test

It is important to ensure that facial hair does not cross the respirator sealing surface and if the respirator has an exhalation valve, hair within the sealed mask area should not impinge upon or contact the valve. Respirators should be compatible with other facial protection used (protective eyewear) so that this does not interfere with the seal of the respiratory protection.


Hair covers

Scrubs, cotton socks, clogs

Disposable gloves

Disposable gloves must be worn when providing direct patient care and when exposure to blood and or other bodily fluids is anticipated or likely, including during equipment and environmental decontamination. Disposable gloves are subject to single use and must be disposed of immediately after completion of a procedure or task and after each patient contact, as per Standard Infection Control Precautions (SICPs), followed by hand hygiene. Double gloving is not necessary.

A selection of gloves
Non sterile nursing gloves
Non sterile gloves

Disposable coveralls, aprons and gowns

Disposable plastic aprons must be worn to protect staff uniform or clothes from contamination when providing direct patient care and during environmental and equipment decontamination.

Disposable fluid repellent coveralls or long-sleeved gowns must be worn when a disposable plastic apron provides inadequate cover of staff uniform or clothes for the procedure or task being performed, and when there is a risk of splashing of bodily fluids such as during AGMPs in higher risk areas or in operative procedures. If non-fluid-resistant gowns are used, a disposable plastic apron should be worn. If extensive splashing is anticipated then use of additional fluid repellent items may be appropriate.

Disposable aprons are subject to single use and must be disposed of immediately after completion of a procedure or task and after each patient contact as per SICPs. Hand hygiene should be practiced as per SICPs and extended to exposed forearms. Disposable fluid repellent coveralls or long-sleeved gowns are for single use or for single session use in certain circumstances but should be discarded at the end of a session or earlier if damaged or soiled.

If the coveralls have no integrated foot section, clogs need to be used in combination with boot covers to prevent the contamination of feet.


Boots and boot covers

Sessional or single use PPE

Aprons and gloves are subject to single use as per SICPs, with disposal and hand hygiene after each patient contact.

Respirators, fluid-resistant (Type IIR) surgical masks (FRSM), eye protection and disposable fluid repellent coveralls or long-sleeved disposable fluid repellent gowns can be subject to single session use in certain circumstances .

A single session refers to a period of time where a healthcare worker is undertaking duties in a specific clinical care setting or exposure environment. For example, a session might comprise a ward round, or taking observations of several patients in a cohort bay or ward. A session ends when the healthcare worker leaves the clinical care setting or exposure environment. Once the PPE has been removed it should be disposed of safely. The duration of a single session will vary depending on the clinical activity being undertaken.

While generally considered good practice, there is no evidence to show that discarding disposable respirators, face masks or eye protection in between each patient reduces the risk of infection transmission to the healthcare worker or the patient. Indeed, frequent handling of this equipment to discard and replace it could theoretically increase risk of exposure in high demand environments, for example, by leading to increased face touching during removal. The rationale for recommending sessional use in certain circumstances is therefore to reduce risk of inadvertent indirect transmission, as well as to facilitate delivery of efficient clinical care.

PPE should not be subject to continued use if damaged, soiled, compromised or uncomfortable, and a session should be ended in these circumstances. While the duration of a session is not specified here, the duration of use of PPE items should not exceed manufacturer instructions. Appropriateness of single versus sessional use is dependent on the nature of the task or activity being undertaken and the local context.

Sources & links

  • ECDC | ECDC Tutorial: Critical aspects of the safe use of PPE | Link
  • ECDC | Guidance for wearing and removing PPE in healthcare settings | Link
  • UKGOV | Link
  • WHO | PPE guide (PDF) | Link

LMIC solutions: N95 equivalencies

Introduction / overview

N95 respirators and surgical masks are examples of personal protective equipment (PPE) that are used to protect the wearer from airborne particles and from fluid contaminating the face.

An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. Note that the edges of the respirator are designed to form a seal around the nose and mouth. N95 respirators are commonly used in healthcare settings and are a subset of N95 Filtering Facepiece Respirators, often referred to as N95s.

Some N95 respirators are intended for use in a healthcare setting. Specifically, single-use, disposable respiratory protective devices are used by healthcare personnel during procedures to protect both the patient and healthcare worker from the transfer of microorganisms, bodily fluids, and particulate material. 

Understanding the Difference
Surgical MaskThis image has an empty alt attribute; its file name is pic-surgical-mask.jpgN95 RespiratorThis image has an empty alt attribute; its file name is pic-n95-respirator.jpg
Testing and ApprovalCleared by the U.S. Food and Drug Administration (FDA)Evaluated, tested, and approved by NIOSH as per the requirements in 42 CFR Part 84
Intended Use and PurposeFluid resistant and provides the wearer protection against large droplets, splashes, or sprays of bodily or other hazardous fluids. Protects the patient from the wearer’s respiratory emissionsReduces wearer’s exposure to particles including small particle aerosols and large droplets (only non-oil aerosols)
Face Seal FitLoose-fittingTight-fitting
Fit Testing RequirementNOYES
User Seal Check RequirementNOYes. Required each time the respirator is donned (put on)
FiltrationDoes NOT provide the wearer with a reliable level of protection from inhaling smaller airborne particles and is not considered respiratory protectionFilters out at least 95% of airborne particles including large and small particles
LeakageLeakage occurs around the edge of the mask when user inhalesWhen properly fitted and donned, minimal leakage occurs around edges of the respirator when user inhales
Use LimitationsDisposable. Discard after each patient encounter.Ideally should be discarded after each patient encounter and after aerosol generating procedures. It should also be discarded when it becomes damaged or deformed; no longer forms an effective seal to the face; becomes wet or visibly dirty; breathing becomes difficult; or if it becomes contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.
Source: Centers for Disease Control (https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf )

3M comparison of KN95, FFP2, and N95 filtering facepiece respirators across the world.

Filtering facepiece respirators, sometimes called disposable respirators, are subject to various regulatory standards around the world. These standards specify certain required physical properties and performance characteristics in order for respirators to claim compliance with the particular standard.

During pandemic or emergency situations, health authorities often reference these standards when making respirator recommendations, stating, for example, that certain populations should use an “N95, FFP2, or similar” respirator.

This article is intended to help clarify some key similarities between such references, specifically to the following FFR performance standards:

  • N95 (United States NIOSH-42CFR84)
  • FFP2 (Europe EN 149-2001)
  • KN95 (China GB2626-2006)
  • P2 (Australia/New Zealand AS/NZA 1716:2012)
  • Korea 1st Class (Korea KMOEL – 2017-64)
  • DS2 (Japan JMHLW-Notification 214, 2018)

As shown in the following summary table, respirators certified as meeting these standards can be expected to function very similarly to one another, based on the performance requirements stated in the standards and confirmed during conformity testing.

Sources & links

  • 3M | Comparison of FFP2, KN95, and N95 and other filtering facepiece respirator classes | Link
  • FDA | N95 respirators, surgical masks, and face masks | Link
  • Ontario Health | N95 equivalents as an alternative to N95 respirators in a health care setting | Link (PDF)

Washing hands and skin care during COVID-19

In this exclusive video senior staff nurse Dez demonstrates the correct procedure to wash hands in a hospital environment.

Hi I’m Des, I’m a practice educator, I’m going to be showing you how wash your hands properly before you put on your PPE garments.

Any of the solutions you can use in the scrub, and I have running water in here. I wash my hands first, and I put lots of washing up liquid. Make sure you wash your hands, fingers, between the fingers, and then the back of your hands.

Wash off your soap. Two minutes is quite enough to wash properly. And then more soap, wash off. Your hands should feel very clean.

Dry it using disposable paper towels, make sure you’ve dried it very well before you use your PPE.

Now you’re ready to put your gloves on..

Sources & links

Skin care during COVID-19

Skin Care during COVID-19

Donning and doffing of PPE

This video demonstrates donning droplet and contact PPE.

The first thing as always is hand hygiene.

Make sure you’re not wearing any jewellery, and that your nails are clean and short. When you’re washing your hands make sure to get all surfaces, thumbs, interlacing the fingers, the fingertips, the front and back and the wrists. Keep rubbing until the hands are fully dry. 

Next we will put on the gown. 

Slowly unravel the gown to make sure the gown doesn’t fall to the floor. Make sure to tie both knots at the top and the lower back. It’s important to tie the knot at the lower back because otherwise when you lean over the gown may open and touch any soiled materials.

Procedural mask

Now we will wear our procedural mask. Because we are doing droplet and contact precaution we can wear a procedural mask with an attached visor, or we would wear the procedural mask with other eye protection. When wearing the procedural mask make sure to pinch at the bridge of the nose with both hands to mould it to your face.

For eye protection we will be using a face shield. There are many types of face shield; this is one that may be offered on your unit. For this face shield make sure the three squares at the top are placed on the forehead.


Last but not least we’ll be putting on our gloves. Make sure to wear gloves that are your size, and when you put them on make sure that they cover the cusps of both sides of the gown.

Now we are ready to enter the room and provide care

LMIC Solution

Video from Masanga Hospital, in Sierra Leone. Training video for putting on PPE for COVID-19 patients.

CDC Demonstration of Donning (Putting On) Personal Protective Equipment (PPE)

Sources & links

  • Masanga Hospital | Link

What is the difference between an N95 respirator and a surgical mask?

Procedural and surgical masks; the goal of those is really to prevent large droplets from falling on to the healthcare providers’ mucous membranes.

So nose, mouth, mucous membranes, eyes although the mask doesn’t do that you need to wear eye protection with it.

There’s not really a strong seal around it which is fine as the goal is to catch the droplets.

The N95 respirator on the other hand needs to have a tight seal, and it needs to be fitted to the individual, which is why we do fit testing. Each time that you use it it needs to have a seal check to make sure that that seal works. And you know change and weight change and facial hair all of these things can change that seal. So through your lifetime we need to check those seal checks and and fit testing every couple of years, because our bodies and our face faces change.

So a surgical mask or procedure mask would be indicated when you’re concerned about a viral respiratory illness in general. So we wear it for influenza or for rhinoviruses or any of the common seasonal viruses that circulate. It’s not stand alone we also need a protection and prescription eye not adequate, you need to wear either protective goggles or a visor, or some of the surgical or procedural masks have visors that are built-in.

And together with gloves and gown for the contact component of it.

Respirators are worn for a very specific number of diseases where there’s an airborne transmission component, and the list is actually very small, it’s varicella or chickenpox or disseminated zoster which is also sort of like the second time to get chickenpox, but in a disseminated fashion. Tuberculosis, measles and then there’s some rare emerging diseases where it’s recommended, although the science isn’t clear whether it’s absolutely needed.

Decontamination & disposal of PPE equipment

This video was produced as a guide to PPE conservation strategies that may need to be employed should there be a concern for PPE shortage. It demonstrates the use of an N95 respirator, but the same conservation principles will apply to a mask used for droplet precautions.

Know your fit-tested N95 respirator

In the hallway outside of patient room perform hand hygiene for 15 seconds, making sure you get all surfaces of your hand, including fingertips, wrists and in between your fingers.

Put on yellow isolation gown with opening to the back make sure both ties are tied up behind neck and at waist.

Put on your fit-tested N95 respirator and do a seal check, or put on your droplet mask. Put on full-face shield or eye protection, put on gloves. Make sure gloves go over the cuffs already for patient care.

Going between patient rooms

There is no need to change your N95 droplet mask or face shield unless wet, visibly contaminated or after high risk aerosol eyes generating medical procedures such as intubation.

Move towards the exit door, slowly remove gloves using glove to glove technique for first glove, skin-to-skin for second glove.

Perform hand hygiene for 15 seconds, remove gown touching only inside of gown and rolling away from body. Discard in linen hamper. Hand hygiene for 15 seconds.

Exit room, ensure door is firmly closed. Hand hygiene for 15 seconds, proceed to next room and don new gown and gloves prior to entering the patient room.

Entering a new patient room

Remember when you are wearing your N95 and face shields or droplet mask and visor combination, do not touch your face as face shields in particular may be contaminated.

Vigilant hand hygiene is critical. If you are not sure, just clean your hands again.

Some people may find it difficult to tie their own gown without the face shield touching their hands or their chest, in that case use a buddy to help tie the gown.

When you are doffing your PPE and know you are not going to see another patient in the near future, you should doff your face shield at that time. You can consider taking off your mask if uncomfortable, or if you are planning to spend a long period in a non-clinical area. Remember as long as the N95 respirator or droplet mask was protected by a face shield or another means it is considered clean.

Removing PPE

Remember to remove your mask and sanitize hands when you are leaving the clinical area. Remove N95 respirator or droplet mask by straps in the back, discard down and away from face. Do not touch front of mask perform hand hygiene for 15 seconds.

Re-usability of N95 masks

N95 Mask decontamination: Source: IARS International Aenesthesia Research Society The Infographic is composed by Naveen Nathan, MD, Northwestern University Feinberg School of Medicine (n-nathan@northwestern.edu). Illustration by Naveen Nathan, MD.

The impact of COVID-19 on long-term care management

A conversation between two long-term care physicians about how COVID-19 has changed the way they provide patient care.

Anne: You told me last time that there’s really not that much difference in terms of pre-COVID in planning when you’re dealing with residents and their families, because a lot of the preparation pre-COVID days you’ve already done. Right when they come in when they’re admitted. So the first question is ‘how have things changed due to the current pandemic?

Brian: I think that the biggest thing that I’m appreciating from the nursing staff as we’re talking today, I’ve even met this patient yet in the flesh I just went over orders and stuff along that line, and I see from her chart that somebody whether it was the nurse practitioner or the nurses got a no see a DNR order on the patient right from the get-go when she came in. And I would bet that there’s a little bit more importance put to that during COVID-19 because the fact that god forbid if we do get it into the institution it’s gonna be very very hard to keep it from going from floor to floor to floor.

It was actually back in early 2000s that I forget what the outbreak was that we had in seniors health center, and at that point in time couple of the floors got together on one floor for meals and through some donations and the North York Foundation whatever they were able to reconfigure some of the space so that each of the four floors has a dining area on their own floor. So that there’s a at least an opportunity to try and isolate any kind of outbreak onto one floor, and we’ve been successful to do that many times over the years that I’ve been there. So that was a huge plus. Nursing homes of the future I have no idea how they’ll do it now we’ll probably all be single rooms, how they’re gonna do it to existing places I can’t imagine, I just can’t imagine.

Anne: What’s the most number of residents per room that you have?

Brian: We have some ward rooms, four bedrooms not a lot of them, but certainly at least a couple of floors so that, oh well, four floors only single rooms. But I guess on the others we probably have at least six four bedrooms in the in the institution, at least that, and almost all the other rooms are double, and the fourth floor is sort of the executive floor. It’s more costly because they’re almost all single rooms, and some of them are even like husband and wife not a lot of those, but sometimes there are a husband and wife in some of the larger rooms.

Anne: So has Infection Control commented whether we should be using fewer of the I guess they call ‘Ward type rooms’ and more of the single rooms, if you have a capacity?

Brian: It’s come out in directives but I don’t know specifically who from, where, but that’s gotta be something that they’re going to have to look at, but as I said what they can do to existing structure … I mean I don’t know, you’re talking about major and even then you couldn’t you could theoretically convert them into two two bedrooms, but it would still take a fair bit of construction. You know the suction and oxygen the whole business, but otherwise you’re decimating the number of residents you can have in the institution. Craziness, but moving forward I would bet that that’s what they’re gonna have to do.

Anne: If you are building a new long-term care facility?

Brian: I would put in all solitary rooms, all single rooms.

Anne: What about the rooms where they share a bathroom in the middle? They look like single rooms but they’re actually doubles, but they have a bathroom in the middle, is that safe during pandemics?

Brian: No I mean no but even our double rooms it’s one bathroom in that suite, there’s not even like one on either side both of them using that bathroom. The four bedroom it’s one bathroom so as I say the retrofit I can’t I can’t imagine but new construction I would bet that that will be where it’s all at.

Anne: Solitary rooms with a bathroom in each room.

And the other thing is you have enough rooms maybe not every room but you have for the sake of argument a quarter of the rooms that have the negative pressure ability, to really, really isolate the patient. A respiratory or that kind of problem. I mean the two major two major problems that we get must be the same as you is either a GI outbreak you know like Norwalk, and we’ve been very very fortunate in my 20 years maybe two or three outbreaks maybe like not a lot. But then we’ll get influenza outbreaks.

So then the real question is can we confine it to just one floor or two floors, of the four floors, so they really try and wiggle around the staff to not do a lot of moving from floor to floor or anything along that line. Will they there’s one staff cafeteria type room? Is that a good idea do they have to take much more shift lunch times, spread it out more. New world, I don’t know what all the answers are to this but it’s got to be a bit of a new world because even then, if you’ve got the floors isolated if the staff can then congregate, somebody from the first floor, the third floor the fourth floor going to meet for lunch in the cafeteria, sit at the same table. I don’t know.

Anne: I think we need bigger tables in our in our place because in our nursing home the tables are not six feet, you’re not sitting six feet apart and now that we have this directive of six feet. I’ve never had experience with this before, this is the first time COVID has made it the first time we actually have to sit six feet away, we’ve had lots of gastroenteritis before but they’ve never had to sit six feet away. So I think going forward I think we would probably have to make bigger tables, or longer tables. The hallways need to be a little bit wider, and I think we would have some units where there are doors. I noticed in yours you have doors that separate the wings, but we don’t have any doors, people only one wing to the next. We’ve got a nursing station in the middle and it’s wide open from one side to the other.

Brian: This was a fire fire code type stuff, they’re all fire walls because we every now and again do have a fire drill, and those doors just close automatically, and all hell breaks loose when they do the drills. Fortunately they usually forewarn us, but yeah.

Anne: We have a lot of wanderers on our floor too, and I noticed that at your home with the doors they’re being shut, it helps to keep the people that wander if they’re COVID positive, you just keep them behind the doors, whereas in ours they kind of move all over the place and we have to have bodies to actually get them redirected back to the rooms.

Brian: Oh yeah yeah.

Anne: So you mentioned before that talking to their families is so important when they are admitted, can you remind me again what did you say about when they come in and then you have the initial conference which is usually between one to six weeks I guess, after they come in, you talk to them about these goals of care. How do you put it to them?

Brian: The goal is to try and see them, speak to them in person within a couple of weeks and I review all of my medical information with them and you know what conditions I’m aware of, have I missed the boat on anything? And I once again especially if dementia is part of the diagnosis I try and advise them right up front that you know this is not going to get better, maybe it’ll stabilize somewhat but it’s gonna gradually get worse and worse and worse, and unless something else takes your loved one the dementia itself will be the terminal event. And how long have you had it average length is about six to seven years from initial diagnosis to the end, so you got to be prepared that you know one day your mother is gonna forget how to swallow, forget how to chew, and not be able to eat. So we’ve got to prepare ourselves emotionally and mentally that that might be.

And then the the big talk. It’s been an adjustment over the 20 years as far as what are what we get them to sign so to speak. At one point in time when I first started there there were like four choices as to what to do as far as end-of-life or advanced care directives. Right now it’s basically CPR, no CPR. And ideally sometimes we’ll talk about transfer to hospital type situation, and I explained to them that if something acute happens that is reversible, something like falling and fracturing a hip, or a fracturing a wrist, it’s unfortunate if that were to happen, hopefully it won’t happen but of course we would send your loved one to the hospital to get x-rayed and tested.

But otherwise if it’s just a significant event, but one that is not likely going to be easily reversed: a bad pneumonia, a heart attack, a stroke – do you really insist that we send the patient to hospital? It’s just not by any means that they’re going to get better or do you allow us to keep your loved one as comfortable as we possibly can here, we’re very comfortable with the fact that people do pass away here .. it’s it’s reality and that somebody’s got to die sometime. We’re not in a hurry to have that happen, but it will happen sometime, and just going to a hospital it doesn’t mean you’re gonna recover, and if anything that I put it on myself; from a personal standpoint I can’t imagine anything more disruptive that when you’re in your last hours or days that you’re taken by ambulance guys who you’ve never met before on a stretcher outdoors, it might be middle of winter, into an ambulance to go to a hospital. A bunch of people again who don’t know you, rather than staff who have been taking care of you for six months, six years. And it doesn’t mean doesn’t mean you’re gonna get better. So I couch it in those kinds of terms …

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

Protocols for rationing strategies & allocation systems

Introduction / overview

  1. Non-abandonment: Healthcare providers have a duty to provide care. No person in need of medical care should ever be neglected or abandoned. Palliative care must be accessible for all patients with respiratory failure for whom life sustaining treatment such as mechanical ventilation will be withheld or withdrawn
  2. Health systems have a duty to responsibly and equitably manage resources
  3. Health systems have a duty to plan for these scenarios to avoid placing the burden on frontline healthcare workers
  4. Rationing systems should ensure just and equitable allocation of resources
  5. Protocols and decisions must be transparent

Procedures to consider for allocation systems

  1. Utilise an officer or committee not involved in caring for the patient to guide decisions. This can help avoid individual health care workers from making tough decisions alone
  2. A simple system might include:
  • Assessing eligibility: Exclusion criteria for advanced care resources may include factors that will lead to near-term death regardless of intervention (e.g. cardiac arrest, irreversible septic shock and/or organ damage, severe traumatic brain injury)
  • Standardise risk assessment: A replicable way for an officer or committee to use clinical data to assess mortality risk can help determine patients most likely to survive coronavirus infection. One example is the Sequential Organ Failure Assessment (SOFA) calculator
  • Reassess at routine intervals: Decisions should be ongoing as clinical parameters change
  • Transparency: The procedures should be easily accessible and understandable at an elementary school level and in all major languages in the institution’s catchment area
  • Reciprocity and social usefulness during the pandemic: Providers of critical services, especially those who face disproportionate risk in helping others, should have a proportional return for their contributions such as priority in access to PPE, testing, treatment and psycho-social support. These might include doctors, nurses, midwives, housekeepers, sanitation workers, morgue workers, and emergency medical workers
  • Vulnerable populations:
    • Patients who are vulnerable due to age, gender, sexual identity, race/ethnicity, disability, poverty, homelessness, social isolation, or any other form of discrimination may require more or more intense psycho-social services than others
    • Patients who are particularly vulnerable to infection due to chronic illness or disability, or to their living situation, may require enhanced protective measures

Sources & links:

  • International Monetary Fund | A matter of life and death | Link
  • AHRQ | Allocation of scarce resources during pandemics: strategies for policy makers | Link

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