GUIDELINES &

STANDARD OPERATING PROTOCOLS (SOPs)

FOR COVID-19

Case definition

Suspect case

A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease,

e.g., cough, shortness of breath), AND a history of travel to or residence in a location reporting

community transmission of COVID-19 disease during the 14 days prior to symptom onset;

OR

A patient with any acute respiratory illness AND having been in contact with a confirmed or

probable COVID-19 case in the last 14 days prior to symptom onset;

OR

A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory

disease, e.g., cough, shortness of breath; AND requiring hospitalization) AND in the absence of an

alternative diagnosis that fully explains the clinical presentation

Probable case

A suspect case for whom testing for the COVID-19 virus isinconclusive.

OR

A suspect case for whom testing could not be performed for anyreason.

Confirm case

A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs

and symptoms.

Clinical Features

COVID-19 patients reporting to various Covid treatment facilities have reported the following

signs and symptoms:

Fever

Cough

Fatigue

Shortness of breath

Expectoration

Myalgia

Rhinorrhea, sore throat, diarrhea

Loss of smell (anosmia) or loss of taste (ageusia) preceding the onset of respiratory

symptoms has also been reported

Older people and immune-suppressed patients in particular may present with atypical symptoms

such as fatigue, reduced alertness, reduced mobility, diarrhoea, loss of appetite, delirium, and

absence of fever. Children might not have reported fever or cough as frequently as adults.

As per data from Integrated Health Information Platform (IHIP)/ Integrated Disease Surveillance

Programme (IDSP) portal case investigation forms for COVID 19 (n=15,366),fever (27%), cough

(21%), sore throat (10%), breathlessness (8%), Weakness (7%), running nose (3%)

and others 24%.

Laboratory Diagnosis

Sample collection

Preferred sample Throat and nasal swab in viral transport media (VTM) and transported

in cold chain.

Alternate Nasopharyngeal swab, BAL or endotracheal aspirate which has to be

mixed with the viral transport medium and transported in cold chain.

General guidelines

Use appropriate PPE for specimen collection (droplet and contact precautions for URT

specimens; airborne precautions for LRT specimens). Maintain proper infection

control when collecting specimens

Restricted entry to visitors or attendants during sample collection

Complete the requisition form for each specimen submitted

Proper disposal of all waste generated

Respiratory specimen collection methods:

A. Lower respiratory tract

Bronchoalveolar lavage, tracheal aspirate, sputum

Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile

dry container.

B. Upper respiratory tract

Nasopharyngeal swab AND oropharyngeal swab

Oropharyngeal swab (e.g. throat swab): Tilt patient’s head back 70 degrees. Rub swab over both

tonsillar pillars and posterior oropharynx and avoid touching the tongue, teeth, and gums. Use only

synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden

shafts. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media.

Combined nasal & throat swab: Tilt patient’s head back 70 degrees. While gently rotating the

swab, insert swab less than one inch into nostril (until resistance is met at turbinates). Rotate the

swab several times against nasal wall and repeat in other nostril using the same swab. Place tip of

the swab into sterile viral transport media tube and cut off the applicator stick. For throat swab, take

a second dry polyester swab, insert into mouth, and swab the posterior pharynx and tonsillar areas

(avoid the tongue). Place tip of swab into the same tube and cut off the applicator tip.

Nasopharyngeal swab: Tilt patient’s head back 70 degrees. Insert flexible swab through the nares

parallel to the palate (not upwards) until resistance is encountered or the distance is equivalent to

that from the ear to the nostril of the patient. Gently, rub and roll the swab. Leave the swab in place

for several seconds to absorb secretions before removing.

Clinicians may also collect lower respiratory tract samples when these are readily available (for

example, in mechanically ventilated patients). In hospitalized patients in Dedicated Covid Hospitals

(severe cases with confirmed COVID - 19 infection, repeat upper respiratory tract samples should

be collected to demonstrate viral clearance.

Recommended Test

Real time or Conventional RT-PCR test is recommended for diagnosis. SARS-CoV-2 antibody

tests are not recommended for diagnosis of current infection with COVID-19.

Dual infections with other respiratory infections (viral, bacterial and fungal) have been found in

COVID-19 patients. Depending on local epidemiology and clinical symptoms, test for other

potential etiologies (e.g. Influenza, other respiratory viruses, malaria, dengue fever, typhoid fever)

as appropriate.

For COVID-19 patients with severe disease, also collect blood cultures, ideally prior to initiation of

antimicrobial therapy

Infection Prevention and Control (IPC) Measures

IPC is a critical and integral part of clinical management of patients and should be initiated at

the point of entry of the patient to hospital. The same should be continued in the designated

ward for in-patient care of suspected and confirmed cases. At AIIMS the following areas

have been identified for the care of suspected and confirmed patients

Implementing IPC measures for patients with suspected or confirmed 2019-nCoV

infection

Situation Measures

At triage ● Suspected patients to be triaged at the screening area in front of

OPD BLOCK The promotion of hand hygiene and respiratory

hygiene are essential preventive measures (appropriate

signage’s)

● Give suspected patients a medical mask

● Instruct all patients to cover nose and mouth during coughing or

sneezing with tissue or flexed elbow

● Perform hand hygiene after contact with respiratory secretions

● Keep at least 1-2 meters distance between suspected patients

● Adequate supplies including alcohol-based hand rub (ABHR),

tissues, no touch receptacles for disposal, and facemasks at

designated areas

● Healthcare Worker (HCW) to use a N95 respirator/three-layered

medical mask during work in designated areas

● Use Personal Protective Equipment (PPE) (N95

respirator/medical mask, eye protection, gloves and gown) when

entering room and remove PPE when leaving

● Use 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.

● Health care workers should refrain from touching their eyes,

nose, and mouth with potentially contaminated hands.

● Avoid contaminating environmental surfaces (e.g. door handles

and light switches).

● When providing care in close contact, use eye protection

(goggles)

Transfer to designated

cubicle in isolation ward

& Intra-hospital transfer of

patients

● Use predetermined transport routes to minimize exposure for

staff, other patients and visitors

● Standard, droplet and contact precaution as above

● Restrict visitor access to patients

● Provide dedicated diagnostic and therapeutic devices including

portable ultrasonography, electrocardiography, mechanical

ventilation, and cardiorespiratory monitoring equipment within

the designated patient areas.

● In case of requirement of procedures like computed tomography

(CT scan) or operative procedures which necessitate shifting,

this may be scheduled during out-of-routine work hours

● The hospital personnel involved in shifting and managing the

patient outside designated areas should follow all standard

contact and droplet precautions.

● All specimens collected for laboratory investigations should be

regarded as potentially infectious; reinforce safe handling

practices and spill decontamination procedures for staff

transporting the samples

Apply airborne precautions

when performing an aerosol

generating procedure

Includes open suctioning of

respiratory tract, intubation,

bronchoscopy,

Cardiopulmonary

resuscitation (CPR)

● Healthcare workers performing aerosol-generating procedures

should use PPE, including gloves, long-sleeved non-permeable

gowns, eye protection, and N95 respirator

● Adequately ventilated single rooms should be used performing

aerosol-generating procedures. Single isolation room in C6 ward

has been identified for this purpose.

* Standard precautions should always be applied. Additional contact and droplet

precautions should continue until the patient is asymptomatic.

Standard precautions should always be routinely applied in all areas of health care facilities

including OPD. Standard precautions are summarized below:

● Hand hygiene-

o Healthcare providers (HCP) should perform hand hygiene using alcohol-based

hand rub or by washing with soap and water for at least 20 seconds. If hands are

visibly soiled, use soap and water before returning to ABHR

● Use of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including

respiratory secretions) and non-intact skin.

o An area is designated for donning and doffing PPE in the immediate vicinity

o Gloves- Perform hand hygiene then put on clean, non-sterile gloves upon entry

into the patient room or care area. Change gloves if they become torn or heavily

contaminated. Remove and discard gloves when leaving the patient room or care

area, and immediately perform hand hygiene

o Gowns- Put on a clean disposable non-permeable gown prior to entry into the

patient room or area. Change the gown if it becomes soiled. Remove and discard

the gown before leaving the patient room or care area.

o Respiratory Protection- Use respiratory protection, i.e. as follows:

i. Three-layered medical mask to be worn by patients at all times

ii. A disposable N95 respirator to be worn by Health Care Providers

(HCPs). Disposable respirators should be removed and discarded after

exiting the patient’s room or care area. Perform hand hygiene after

discarding the respirator.

Out PatientDepartment

ADMINISTRATION

Sr.

No.

Setting Activity Risk Recommende

d

PPE

Remarks

1 Administrative

staff

Providing

administrative

support

No risk No PPE No contact with patients

ofCOVID-

19. They should not

venture into areas with

suspect COVID-19.

S No Setting Activity Risk Recommended

PPE

Remarks

1 Help desk/

Registration

counter

Provide

information

to patients

Mild risk Triple layer medical

mask

Latex examination gloves

Physical distancing

to be followed at all

times

2 Doctors

chamber

Clinical

management

Mild risk Triple layer medical

mask

Latex examination gloves

No aerosol

generating

procedures allowed.

3 Chamber of

Dental/ENT

doctors/

Ophthalmology

doctors

Clinical

management

Moderate

risk

N-95 mask Goggles

Latex examination gloves

Aerosol generating

procedures

anticipated.

+ face shield Face shield, when a

splash of body fluid

is expected

4 Pharmacy

counter

Distribution

of drugs

Mild risk Triple layer medical

mask Latex examination

gloves

Frequent use of hand

sanitizer is advised

over gloves.

Sanitary staff Cleaning Mild risk Triple layer

frequently medical mask

touched

surfaces/

Latex examination gloves

Floor

Hospital Setting

Outpatient Department (Triage area/ Separate screening area)

S. No Setting Activity Risk Recommended

PPE

Remarks

1 Triage area Triaging patients

Provide

triple layer

mask to

patient.

Moderate risk PPE

N 95

mask

Gloves

Patients get

masked.

2 Screening area

help desk/

Registration

Counter

Provide

information

to patients

Moderate risk N-95 mask

Gloves

Social distance

to be maintained.

3 Holding area/

waiting area

Nurses /

paramedic

interacting

with patients

Moderate Risk N 95 mask

Gloves

Minimum

distance of

one meter

needs to be

maintained.

4 Doctor

chamber

Clinical

management

(doctors,

nurses)

Moderate Risk N 95 mask

Gloves

No aerosol

generating

procedures

should

be allowed.

5 Sanitary staff Cleaning

frequently

touched

surfaces/

Floor/

cleaning

Linen

Moderate risk N-95

mask

Gloves

6 Visitors

accompanying

young children

and elderlies

Support in

navigating

various

service

areas

Low risk Triple layer

medical mask

No other

visitors should

be allowed to

accompany

patients in

OPD settings.

The visitors

thus allowed

should practice

hand

Hygiene

7 Pharmacy

counter

Distribution

of drugs

Mild risk Triple layer

medical mask

Latex

examination

gloves

Frequent use

of hand

sanitizer is

advised over

gloves.

Social distance

to be

maintained.

In-patient Services

S. No. Setting Activity Risk Recommended

PPE

Remarks

1 Individual

isolation rooms/

cohorted

isolation rooms

Clinical

manageme

nt

Moderate risk N 95

mask

Gloves

Patient

masked.

Patients

stable. No

aerosol

generating

activity.

2 Sanitation Cleaning

frequently

touched

surfaces/

floor/

changing

linen

Moderate risk N-95

mask

Gloves

3 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

infectio

n

preventi

on

control

practice

s.

No

possibility

of

exposure to

COVID

patients.

They

should not

venture

intoCOVI

D-19

treatmentar

eas.

4 Caretaker

accompanying

the admitted

patient

Taking

care of the

admitted

patient

Low risk Triple

layer

medical

mask

The

caretaker

thus

allowed

should

practice

hand

hygiene,

maintain a

distance of

1meter

EmergencyDepartment

S.No Setting Activity Risk Recommended

PPE

Remarks

1 Emergency Attending

emergency

cases

Moderate risk PPE,

N 95 mask

Gloves

No aerosol

generating

procedures

areAllowed

Pre-hospital (Ambulance) Services

S.No. Setting Activity Risk Recommended

PPE

Remarks

1 Ambulanc

e Transfer

to

designate

d hospital

Transporting patients

not on any assisted

ventilation

Low risk Triple layer medical

mask Latex

examination

gloves

Management of SARI

patient

High

risk

Full complement of

PPE (N-95 mask,

cover all, goggle,

latex examination

gloves, shoe cover)

While

performin

g aerosol

generating

procedure

Driving the ambulance Low risk Triple layer medical

mask

Latex examination

gloves

Driver helps

in shifting

patients to

the

emergency

Other Supportive/ Ancillary Services

S. No. Setting Activity Risk Recommended

PPE

Remarks

1. Laboratory Sample collection

and transportation

High risk Full

complement

of PPE

Sample testing High risk Full

complement

of PPE

2 Sanitation Frequent cleaning

of touched

surfaces/ floor.

Cleaning

linen in COVID

treatmentareas

Moderate risk N-95

mask

Gloves

3 CSSD/Laundry Handling linen of

COVID patients

Moderate risk N-95 mask

Gloves

4 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.

Quarantinefacility

S. No. Setting Activity Risk Recommended

PPE

Remarks

1 Persons

being

quarantined

Low Risk Triple layer mask

2 Healthcare

staff working

at quarantine

facility

Health monitoring

and temperature

recording

Low Risk Triple layer

mask Gloves

Clinical

examination of

symptomatic

persons

Moderate

Risk

N-95 masks

Gloves

3 Support staff Low Risk Triple layer

mask

Gloves

Obstetrics and Gynecology Department, post COVID-19 protocol {SOP}

Executive Summary

Measures for Pregnant Women to Prevent COVID-19 infection Social Distancing –

could be the single most important intervention at population level.

Do the Five – Staying at home, Hand hygiene, Respiratory hygiene, avoiding touching

the face and Keeping distance should be practiced. Wearing a mask is recommended.

Precautions for healthcare workers (HCW)

HCW are at high risk of getting infected. Precautions are necessary to protect themselves

and prevent spread to others.

Distancing – where possible, HCW should keep a distance and practice hand hygiene

Personal Protective Equipment (PPE) – use should be according to clinical situation.

Covering of all surfaces especially hands and face is vital. Proper technique to wear and

remove PPE is essential.

Chemoprophylaxis – is recommended with Hydroxychloroquine only for HCW with

known contact of COVID-19 positive patients. In case of accidental exposure, complete

protocol should be followed.

The three principles that healthcare workers should follow are distancing, use of

appropriate PPE correctly and chemoprophylaxis.

As for the general population, the healthcare worker should also consider Social

distancing as the cornerstone of prevention whenever possible.

The following measures may be useful in addition to appropriate gear.

Maintain a distance of at least 1 meter from patients and other healthcare workers.

However, this may not be feasible during examination, inpatient care and procedures.

Remove non-essential items from the consulting or examination room to facilitate

cleaning and disinfection and reduce the risk of fomites related spread.

Regular hand cleaning with soap and water or alcoholbased rubs for at least 20 seconds

Testing for COVID-19 in Pregnancy

The criteria for testing non-pregnant persons are applicable to pregnant women. In

addition, there are some special criteria for testing with regards to pregnancy. It is

essentially meant for acute respiratory illness with exposure, travel, contact or a HCW or

requiring hospitalization.

Asymptomatic individuals should be tested between 5 to 14 days of exposure to a known

contact.

Symptomatic individuals with influenza like illness from hotspots should be tested by

RT-PCR (within 7 days) or serology (after 7 days).

Pregnant women residing in cluster/ containment areas or in large migration

gatherings/evacuees centre from hotspot districts presenting in labour or likely to deliver

in next 5 days should be tested even if asymptomatic.

There is no recommendation for testing every pregnant woman.

Test methods and facilities

Presently the RT-PCR test from nasopharyngeal swab is used for diagnosis. Other

investigations

Supportive investigations include blood studies for infection and systemic assessment and

imaging by X-ray or CT scan chest with abdominal shielding.

Effects of COVID-19 infection on the foetus

There areemerging evidence from immunological assessment that in-utero transplacental

infection to the foetus may occur.

The virus has not been isolated in amniotic fluid or vaginal secretions.

The neonatal effects seem to be minimal.

Assessment of Pregnant women (not in labour)

Recognizing the critically ill woman – Most women will not need hospitalization or

critical care. Tachypnoea (>30/min), hypoxia (SpO2 < or = 93%) and imaging showing >

50% lung involvement indicate a need for critical care.

Diet for the pregnant woman and COVID-19 infection should be as per routine. There are no

special diets. A nutritious diet helps to build immunity.

Measures for Pregnant Women to Prevent COVID-19 infection

The greatest tool to prevent COVID-19 Infection in the general population and for

pregnant women is Social Distancing. As per the Government of India advisory, this is a

non-pharmaceutical infection prevention and control intervention implemented to avoid

contact between those who are infected with a disease and those who are not, so as to

stop or slow down the rate and extent of disease transmission in a community. Some

important aspects for the pregnant woman in India from this advisory are:

Disinfection of surfaces to reduce fomites related spread. For women working outside

the house, it is preferable to take work from home. Keeping a distance of at least one

metre in various necessary interactions and activities Avoid non-essential travel. If travel

is undertaken, it is preferable to use a private vehicle. If public transport is used, distance

should be maintained. Avoid gatherings and functions such as to celebrate the 7-month

milestone and others, which is a common cultural practice. Minimize visitors from

coming to meet the mother and newborn after delivery.

Pregnant women are a special category in terms of healthcare. They should therefore,

follow these guidelines fastidiously.

They can protect themselves by the motto “Do the Five”.

The principle elements of this are:

Home Stay at home as much as possible unless there is a medical need related to

development of symptoms of infection or related to pregnancy. Routine antenatal visits

are to be deferred. If there is a minor query, it can be sorted out telephonically. Keep the

traffic of home visitors including homecare personnel, maids, and staff members to a

minimum or avoid completely if possible.

HandsWashing hands frequently and properly with a soap and water or an alcohol-based

hand rub for minimum 20 seconds

Elbowcovering mouth and nose with their bent elbow, handkerchief or tissue while

coughing or sneezing. Then the used tissue should be disposed immediately. This is an

important component of respiratory hygiene.

FaceAvoid touching face, eyes, nose and mouth with hands.

SpaceKeep a distance of at least 1 meter from the next person outside and in the house.

Testing for COVID-19 in Pregnancy

Indications (Criteria) The currently recommended indications for testing for the general

population (which also apply to pregnant women) as per the ICMR given on 09 April

2020 are as follows:

o All symptomatic individuals who have undertaken international travel in the last

14 days

o All symptomatic contacts of laboratory confirmed cases

o All symptomatic health care workers Note – The term “symptomatic” is

interpreted as symptoms of acute respiratory illness (fever with a respiratory

symptom such as cough, congestion, sore throat or shortness of breath).

o All patients with Severe Acute Respiratory Illness (fever AND cough and/or

shortness of breath). These are patients who have a severe illness which requires

hospitalization.

o Asymptomatic direct and high-risk contacts of a confirmed case should be tested

once between day 5 and day 14 of coming in his/her contact

As per the guidance from the Government of India, direct and high risk contact is defined

as those living in the same household, traveling together by any conveyance, working

together in close proximity (same room), or healthcare workers providing direct care.

In hotspots/cluster (as per MoHFW) and in large migration gatherings/ evacuees centres:

o All symptomatic ILI (fever, cough, sore throat, runny nose). (ILI is an

abbreviation for Influenza Like Illness.) a. Within 7 days of illness – RT-PCR b.

After 7 days of illness – Antibody test (If negative, confirmed by RT-PCR)

Recently, pregnant women have been classified as a special category for testing and the

current specific recommendations which have been added for them are:

o Pregnant women residing in cluster/containment areas or in large migration

gatherings/evacuees centre from hotspot districts presenting in labour or likely to

deliver in next 5 days should be tested even if asymptomatic. The guidance

further states that the testing should be carried out in the center where the woman

is admitted for delivery and she should not be referred out for testing.

Note – Healthcare providers should be updated about the local conditions and the

hotspots/clusters in their area. These change as per contact tracing and are updated

regularly at https://www.mohfw.gov.in/

This testing strategy may evolve, and recommendations may change.

We believe that a pregnant woman who is in labour with any (not all) of the symptoms of

SARI will be benefited if tested for COVID-19 infection. At present, this is not

recommended by ICMR, but may be included in future in the testing criteria, once the

rapid tests are available, which may be useful to the mother, neonate and healthcare

workers.

COVID-19 Screening Checklist Tool

Do you have fever?

Do you have features of respiratory disease (runny nose, altered smell sensation, blocked

nose, cough, sore throat, difficulty in breathing or feeling breathless)?

Do you have travel abroad / interstate in the last 14 days?

Have you travelled from anywhere outside your locality in the last 14 days? If yes, was

this area a hotspot?

Do you have household or close and direct contact with a person who meets the above

two criteria of travel?

Do you have household or close and direct contact with a person who is confirmed to

have COVID-19 infection or who is suspected and undergoing testing?

Routine Antenatal Care during the pandemic

Antenatal Care Visits Following the principles of social distancing, it is advisable to

minimize the number of visits that a pregnant woman needs to leave her house. There is a

minimum level of antenatal care and investigations which are necessary.

An ultrasound is advised at 12-13 weeks and at 18-22 weeks as outlined below.

Pregnancy visits can be timed with these sonographies. The next visit can be at about 30

to 32 weeks. Vaccinations and antenatal profile (blood and other investigations) can be

planned during these visits.

Growth scans in the last trimester are advised or performed only if indicated. Women are

advised to note foetal movements every day. For women who have high risk factors, the

guidance of the HCP (Health Care Provider) is needed.

Providing Antenatal Care Some useful practices to follow in providing antenatal care are

outlined below to enhance safety and ensure smooth functioning of the clinic.

· Appointments should be scheduled to avoid waiting time and exposure. The

woman should be screened with the checklist tool on the telephone.

· The patient should make the visit alone or at the most, with one attendant.

The patient (and attendant) should leave their shoes outside the waiting room. At entry,

they should use a hand sanitizer correctly. They should be given a mask if they are not

wearing one. If the checklist tool was not administered earlier, it should be done in the

waiting room.

The doctor should wear appropriate PPE (uniform, scrubs or apron with surgical cap,

mask-3 layer or N95 preferably and gloves) while examining the patient.

The consulting room should be kept free from clutter and have the minimum amount of

furniture necessary. The furniture should be hard surfaced to facilitate cleaning. The

patient examination table can have disposable covers where possible.

The number of fomites (mobile phones, electronic devices, pens, measuring tapes,

stethoscopes and BP apparatus) should be kept to a minimum and frequently sanitized. ·

Avoid handling paper, files and reports that the patient brings. It can be seen with the

patient holding them or by photographs. The consulting room should be cleaned

regularly. At the end of the clinic, the examination table should be disinfected. The room

may be fumigated at the end of the day.

Standard Operating Procedure (SOP) of Outpatient management of Orthopedic Patients

during the pandemic of COVID 19

· During the corona virus pandemic, there will be increased emphasis on managing patients

with non-operative strategies and minimizing outpatient visits.

Recommendations of Indian Orthopedic Association and the Ministry of Health and

Family Welfare, Government of India:

The patients should have consultant-delivered, definitive decision-making at first

attendance and, in particular.

Those patients who need immediate management that requires sedation facilities, such as

those with dislocations, may need to remain in the Emergency department and the

Orthopaedic team members should manage these patients here.

Referring doctors and the patients should have a direct telephone access to the

Orthopaedic surgeons to advice to minimise the need for the patients to attend the

hospital. The risk of hospital attendance may outweigh the potential benefit of

intervention, particularly for patients in vulnerable groups.

Impact on radiology services should be minimised. Imaging should be requested after

the patient has been assessed by the Orthopaedic team member, so as to minimise the x-

ray requests and avoid repeat imaging.

Use of removable casts or splints should be maximised to reduce follow-up

requirements.

Routine follow ups must be avoided as far as possible.

Follow-up imaging should only be performed when there is likely to be a significant

change in management. There is no role for imaging to check for fracture union in most

injuries.

Rehabilitation services are likely to be very limited. Alternative resources such as written

and web-based information should be used maximally.

Guidelines to be followed

OPD/ reception screening

Thermal screening: screens for fever, will atleast identify the febrile ones.

Screening by hcw: basic brief history of symptoms: fever, cough, diarrhea, bodyache

T: Travel

O: Occupation

C: Contact

C: Cluster

Aarogyasetu app: see the area where patient belongs.

Minimize OPD patients

Call minimal necessary staff

Health care workers should wear hospital scrubs, masks (n 95 masks), gloves and hospital

shoes

Use telemedicine

One patient one attendant rule

Maintain social distancing

No eating /drinking in waiting area

Keep waiting area vacant

Patient and attendant should wear surgical masks

Easy availabilty and access to sanitisers for everyone.

Should have separate assessment and procedure rooms

Procedure room should be disinfected after every patient with 1% hypochlorite.

Couches should be covered with waterproof sheets/ macintosh/ rexin sheets which can be

disinfected easily.

Give one stop treatment, minimal follow up visits

Avoid interdepartmental referrals, if possible

Minimum xray/investigations

Follow up xrays only when you expect it will have drastic impact of patient’s management

Use videos/online rehab tools for patient rehab.

Management of specific injuries

Dislocations of the joints should be done in the emergency department wherever possible.

If the joint is stable after reduction, the patient should be discharged with appropriate

follow-up.

Most upper limb fractures, including clavicle, humeral and wrist fractures, have high

rates of union and may be managed non-operatively, recognising that some patients may

require late reconstruction.

Ligamentous injuries of the knee may be managed with bracing in preference to early

ligament reconstruction.

Penetrating injuries (stab wounds) to the limbs that are not contaminated and have no

neurological or vascular deficit may be sutured in the emergency department.

Abscesses in patients without systemic sepsis may be incised and drained under local

anaesthetic in the emergency department.

Reference sources:

1. Guidance for surgeons working during the COVID-19 pandemic. The Surgical Royal

Colleges of the United Kingdom and Ireland. 20th March 2020.

https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons/

2. Management of patients with urgent orthopaedic conditions and trauma during the

coronavirus pandemic. British Orthopaedic Association. 24 March 2020.

https://www.boa.ac.uk/resources/covid-19-boasts-combined.html

3. Indian Orthopaedic Association guidelines for management of Orthopaedic Patients

during COVID 19 pandemic.

4. SOP Guidelines for Hospitals issued by the Ministry Of Health and Family Welfare,

Government of India.

https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.p

df

5. Standard Operating Procedure (SOP) for Triage of Suspected COVID-19 Patients in

non-US Healthcare Settings: Early Identification and Prevention of Transmission during

Triage.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/sop-triage-prevent-

transmission.html

Ophthalmology Post COVID Protocol

The patient flow is divided into the areas

1. Patient at Maingate/Entrance

2. Goes tor reception

3. Waitinghall

4. Examination room (VT andDoctor)

5. Advice /Counselling

Main gate/Entrance:

Security

1. Check hands for quarantine stamp on the palm

2. Thermal temperature check in go f everyone–staff,patients,attendants,visitors-

Anyone who enters the premises

3. Give them and their attendants’ sterillium – or make arrangements for hand

wash with soap and water (No attendant allowed, unless the patient is

achildor is disabled).

4. Notedowncontactdetailsofpatients,attendants,andtheirIDcardinaregister

Reception: If possible, to have a shield like what we have at Railway station (or

something like what we have in Pharmacy)

Examination room - VT

One VT per room, no overcrowding

1. To call patients, not to speak to patient when they are coming to the examination

room

2. Tell the patient that you will see the man don’t talking unless asked for

3. Use your own pen and do not share It with anyone

4. Open door policy and good air ventilation

5. Do not take two patients in one room or examine two patients in one room or have

two different VTs in one room.

6. Do auto refractometer while bringing them for examination. Clean the chinrest, fore

head band and the auto refractometer knob after you see the patient with alcohol

wipes. Have a shield on autorefractometer for your protection. Do not unnecessarily

touch patient’s head, Tell the patient to bring his head forward and touch the band

7. To read the patients file before you go out and call the patient– so that

you do not spend time reading the patients file when they are sitting in

the room with you

8. Ask patient to sit in the chair, take history in one go maintaining social distancing

9. Refraction and vision –Protocolattached

10. Clean trial frame, Lenses which you have used including pin hole, occlude

with alcohol wipes. Don’t keep them in these without cleaning those.

11. IOP measurement – case based – ophthalmologist to decide

12. Conjunctivitis patients – you may call the doctor and examine in separate room

13. Dilatation: Anyone with 6/6 and N6 vision (including prebyopes), do not dilate.

However, they would need a through clinical examination including checking of RAPD,

same for, follow ups where it is not needed, should not be dilated. Pull the lower lid

with Johnson bud and then put the dilating drops

14. Do not have patient for more than 10-12 minutes in your room if you are doing

refraction. Do your workups faster, do not waste time during examination. See to it that

you have all supplies in everyroom. Check thisevery dayin the morning before you

start OPD including Doctors room. Do not take patient from one room to the other

room for any examination

15. Clean everything with alcohol wipes / sterillium after you send the patient out. Do not tell

thepatient go to waiting hall/ reception; take them yourself in personand call the next

patient.

16. Take sterillium again before you start examination of the next patient.

17. Syringing: Not to be done. ROPLAS to be checked by the doctors only.

Doctor’s room: No overcrowding, same instructions as above

1. Fundus to be seen in lying down position from head end – Indirect Ophthalmoscopy

or with. +90/78 D lens. Use no touch technique. For indirect ophthalmoscopy, can

use cotton swab stick to open the lids and throw it away.

2. Gonioscopetobewashedwithsoapandwateraftereveryuse.

3. Applanation tonometer prism to be cleaned with 70% isopropyl alcohol sterile

wipes after every patient. The tonometer prism to be dipped twice daily for 5 minutes in

1:10 Sodium hypochlorite solution to disinfect the prisms

4. StopContactLenstrial,directophthalmoscopicevaluation.

5. BCL if needed – only if emergency (not for every patient with defect, post op

pterygium, donotput)– to be placed inlyingdown, putanaestheticdropsand

thentoputthe BCL from headend of the patient with forceps if possible. Ask the

patient to pull the lower lid himself and the doctor to pull the upper lid with Johnson

Bud

6. Reduce follow up visits for all patients – do not call patients such as VKC, Allergic

conjunctivitis, conjunctivitis patients for early follow ups, etc.

7. In case of referrals, give them the violet referral slip and direct them – use your pen

only, do not share the pen. Keep cleaning your pens between two patients if you are

using more often.

8. Do not prescribe NSAID to anypatient

9. Non-mydriatic fundus camera can be used to expedite the examination process

Diagnostics:

Everything should be wiped clean between two patients – you may use 70%

isopropyl alcohol sterile wipes for the same

HVF – Clean trial frames, lenses, chin rest and the head band

Keratometry – Clean the chinrest, headband after every patient – have a barrier

between you and patient

Ascan– Do not go veryclose to thepatientswhiledoing Ascans, cleanprobebetween

two patients

No Phoropter/No Om device to be used during this period till guidelines are

circulated

Syringing: Not to be done. ROPLAS to be checked

Counselling/Checkout:

Do not talk directly facing the patient. Can sit diagonally.

Explain them all the details and schedule surgeries and send the patient out of the

hospital - Patient should not be in the hospital after checkout or counselling is done

Department of General Surgery COVID-19 SOPS

What should be the dress code for surgeons to go to work place and general

Precautions to follow after reaching?

For those engaged in COVID19 critical care, more stringent precautions need to be

carried out to protect oneself, family members and also to reduce the contamination.

Detailed guidelines on surgeon’s attire were published by MoHFW.

While leaving from home

Wear simple dress with shoes & socks

No accessories like watch, ring, tie, coat, wallet

Wear mask

After reaching work place

Change to hospital scrub suite

Change the footwear on entering hospital premise while donning scrubs

Place the travel dress in a cupboard

Wear appropriate mask

Clean your mobile frequently before, during, and after patient care activities. Mobile

phones may be kept in a Ziploc bag during work activities. The phone can be used while

in the bag.

While leaving hospital

Remove the hospital scrub & subject it to proper wash

Addendum: MOHFOW provided recommendations on surgical attire and the steps of surgical

scrub are as follows:

The scrubbing facility: tap and sink, Remove rings, watch and bracelets, Clean the fingernails,

Starting with the fingers, apply soap/ antiseptic to all surfaces of hands, Rub between fingers,

Continue to apply soap/ antiseptic till the elbow, Starting with fingers, rinse each hand and arm

till the elbow with the hands above the level of the elbow, Dry with a sterile towel beginning

with the fingers and till the elbow, Keep the scrubbed hands above the waist level].

Footwear must be made of sturdy, washable material with closed toes to protect the

feet from splashes, and injury due to falling instrument. If footwear are not available

shoe covers can be worn. These are disposable or reusable

What transportation to be used to reach workplace

Commuting to and from hospital will depends on your condition and where you

live. The expert panel recommended reasonable measures to follow during daily

commute to work place.

Best is to use own vehicle

Avoid public transport as much as possible and Govt. approved Taxis

Sanitize hands after getting in & after getting down the vehicle.

In case if commuted through public or shared vehicle, maintain physical distance.

What should be the entry to hospitals & what rules to follow for patients &

healthcare workers during entry and exit from hospital?

Ensure separate entry for healthcare workers and for patients

For patients -­‐ At the entry, a senior health care worker/staff nurse should check the

temperature along with check-­‐ history of fever, signs of cough, throat pain, contact

with fever patients & whether staying in red zone etc.

Staff members must ensure if patients are sanitizing hands and wearing mask properly

or not.

The same protocol must be applicable to all health care workers

What to do after reaching home?

In these unprecedented times, health care providers need to be meticulous to take all

preventive measures available.

Leave footwear outside

Sanitize hand, car keys, mobile

Remove the mask and dispose off appropriately

If reusable cloth mask – put it for wash & rinsing with soap water

Take shower and wear clean dress meant for home

Clean hard surfaces at home with an effective disinfectant solution (e.g. 60% alcohol)

How to schedule appointments?

Despite the fear of COVID-­‐19, routine checkups and regular appointments are crucial in

finding potential health issues

Every one visiting hospital should be wearing mask.

There should be only one entry / exit to patients.

Ask patient to hand sanitize at the entrance.

To rule out fever, a temperature check will also be performed.

Only the patient will be allowed in the office. Minors may have 1 parent/guardian

who may accompany them.

For physically challenged – one relative (properly sanitized)

Instructions to Patient:

Ask your driver / accompanying person to stay in the car during your appointment.

Hospital or you may call your driver when you are ready to leave the facility and escort

you out.

NOTE: If patient or a member of your(patient) household has a cough, fever, and/or

flu-­‐like symptoms or traveled out of the country in the last 8 weeks, please inform

hospital right away as your appointment may be rescheduled.

As per SAGES guidelines, all elective surgical and endoscopic cases should be postponed

duringtheCOVID19crisis.

Precautions to be taken while doing OPD work?

Routine OPD work should be kept to a minimum. This will ensure less crowding

and transmission outside clinics.

No relatives should be allowed in unless unavoidable.

Social distancing must be practiced within clinics and hospitals, with waiting-­‐room

chairs placed six feet apart, and all patients and attendants wear mask in the waiting

area and instructed on cough and sneeze hygiene.

Doctor’s clinics should be well ventilated and patients should be seated and stay

six feet apart except during physical examination.

The doctor should wear a surgical mask, a face shield and scrub hands with soap and

water and use an alcohol-­‐based disinfectant after each patient interaction

Precautions to be taken while doing minor surgery in OPD?

In china, several series of infections were emerged from operating theatre. Hence

adequate knowledge about disease transmission, and institutional infection control

protocols are essential to prevent spread of infection among healthcare workers.

Prevention of COVID19 spread from patient to patient and to healthcare workers is

one of the immediate priorities.

Explain to the patient about the individual risk of coming to the hospital, office, or

surgery centre for surgery during the pandemic.

Perform essential minor surgeries after screening, adequate PPE preferably under local or

regional anaesthesia.

There are many surgical procedures that are not an emergency

Look for non-­‐surgical options if available.

Sr.N

o

Setting Activity Risk Recommended PPE Remark

1. Doctor

chamber

Provide

information

to patient

Mild risk Triple layer mask

Latex

Examinationgloves

No aerosol

generating

procedure

should

be allowed

2. Operation

Theater

Performing

surgery

Moderate

Risk

Triple Layer

Medical

mask/N-95

mask

Face shield

(wherever feasible)

Sterile latex

No aerosol

generating

procedure

should

be allowed

gloves

Case Management

The management will need to be individualized as patient may present with a wide spectrum

of illness ranging from uncomplicated illness, mild pneumonia, severe pneumonia, ARDS,

sepsis and septic shock.

General supportive measures (as per our existing protocols for SARI)

Oxygen supplementation

Conservative fluid management if there is no evidence of shock

Give empiric antimicrobials to treat all likely pathogens causing SARI. Give

antimicrobials within one hour of initial patient assessment for patients with sepsis

Ventilator management as required

Dexamethasone 6 mg daily for 10 days if hypoxia is present.

*Close monitoring for worsening clinical status is of paramount importance (designated

team)

Investigational Therapies

At present, use of these therapies is based on a limited available evidence. As the situation

evolves, and when more data become available, the evidence will be accordingly

incorporated, and recommendation upgraded. Further, use of these drugs is subjected to

limited availability in the country as of now. Currently, these drugs should only be used in a

defined subgroup ofpatients:

Remdesivir(under Emergency Use Authorization)

may be considered in patients with moderate disease (those on oxygen) with none of

the following contraindications:

AST/ALT > 5 times Upper limit of normal(ULN)

Severe renal impairment (i.e., eGFR < 30ml/min/m2 or need for hemodialysis)

Pregnancy or lactatingfemales

Children (< 12 years of age)

Dose: 200 mg IV on day 1 followed by 100 mg IV daily for 5 days

Convalescent plasma (Off Label)

may be considered in patients with moderate disease who are not improving (oxygen

requirement is progressively increasing) despite use of steroids. Special prerequisites

while considering convalescent plasma include:

ABO compatibility and cross matching of the donorplasma

Neutralizing titer of donor plasma should be above the specific threshold (if the

latter is not available, plasma IgG titer (against S-protein RBD) above 1:640 should

beused)

Recipient should be closely monitored for several hours post transfusion for any

transfusion related adverseevents

Use should be avoided in patients with IgA deficiency or immunoglobulinallergy

Dose: Dose is variable ranging from 4 to 13 ml/kg (usually 200 ml single dose given

slowly over not less than 2 hours

Tocilizumab (Off Label)

May be considered in patients with moderate disease with progressively increasing

oxygen requirements and in mechanically ventilated patients not improving despite

use of steroids. Long term safety data in COVID 19 remains largely unknown.

Special considerations before its useinclude:

Presence of raised inflammatory markers (e.g., CRP, Ferritin,IL-6)

Patients should be carefully monitored post Tocilizumab for secondary infections

andneutropenia

Active infections and Tuberculosis should be ruled out beforeuse.

Dose: 8mg/kg (maximum 800 mg at one time) given slowly in 100 ml NS over 1 hour;

dose can be repeated once after 12 to 24 hours if needed.

Repurposed or off-labeltherapies

Hydroxychloroquine:

This drug has demonstrated in vitro activity against SARS-CoV2 and was shown to

be clinically beneficial in several small single center studies though with significant

limitations.

Nonetheless, several large observational studies with severe methodologic limitations

have shown no effect on mortality or other clinically meaningful outcomes.

As such, the evidence base behind its use remains limited as with other drugs and

should only be used after shared decision making with the patients while awaiting the

results of ongoing studies.

As is the case with other antivirals, this drug should be used as early in the disease

course as possible to achieve any meaningful effects and should be avoided in

patients with severe disease.

An ECG should ideally be done before prescribing the drug to measure QTc interval

(and HCQ avoided if QTc is >500ms)

Dose: 400 mg BD on day 1 followed by 400mg daily for next 4 days