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PRACTICE GUIDELINES
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 189-196

Clinical tools and practice guidelines developed for COVID-19 preparedness and use at a secondary care hospital in India


1 Department of Emergency Medicine, NS Hospital, Kollam, Kerala, India
2 Department of Anaesthesiology, Dr. Jeyasekharan Medical Trust, Nagercoil, Tamil Nadu, India

Date of Submission02-May-2020
Date of Decision03-May-2020
Date of Acceptance08-May-2020
Date of Web Publication22-May-2020

Correspondence Address:
Dr. Renu Devaprasath
Department Anaesthesiology, Medical Administrator, Dr. Jeyasekharan Medical Trust, Dr. Jeyasekharan Hospital and Nursing Home, K.P. Road, Kanyakumari, Nagercoil - 629 003, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_73_20

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  Abstract 


The novel coronavirus (SARS-COV-2) that causes the disease coronavirus disease-19 (COVID-19) has posed major challenges for health-care workers worldwide. Once the lockdown is relaxed in India, there might be an increase in the number of positive cases. Simple tools and practice guidelines may make clinical tasks faster, easier, and safer. Toward this objective, governments, hospital administrators, medical associations, health-care providers, and policy-makers worldwide have published multiple papers and guidelines. However, there remain several controversies on the pathophysiology of COVID-19, leading to uncertainty on what should and should not be done. It is in such a context that some simple tools and practice guidelines, based on best available evidence, are being shared on this platform. The contents of these tools have been taken from the World Health Organization guidelines and recent publications on COVID-19. The tools have been designed by a senior anaesthesiologist/medical administrator at a NABH-accredited hospital with over three decades of expertise in the private health-care systems. The purpose of these guidelines is to be prepared to deliver safe and standardized care to COVID-19 patients, while maintaining the ease of work environment for hospital staff. It is understood that all the health-care workers will be wearing personal protective equipment as per the guidelines released by the Ministry of Health and Family Welfare, Government of India. There are nine forms, namely patient workflow, screening form, triage form, COVID-19 severity score tool, outpatient management guidelines, advise; COVID-19 inpatient management guidelines, modified early warning signs chart, and oxygen therapy flow chart. These are simple, on-paper tools, and guidelines for use at secondary care hospitals, in compliance with the governmental regulations.

Keywords: Coronavirus disease-19, guidelines, secondary care hospital, tools


How to cite this article:
Rajenesh A, Indrajit R, Devaprasath R. Clinical tools and practice guidelines developed for COVID-19 preparedness and use at a secondary care hospital in India. Curr Med Issues 2020;18:189-96

How to cite this URL:
Rajenesh A, Indrajit R, Devaprasath R. Clinical tools and practice guidelines developed for COVID-19 preparedness and use at a secondary care hospital in India. Curr Med Issues [serial online] 2020 [cited 2020 Aug 12];18:189-96. Available from: http://www.cmijournal.org/text.asp?2020/18/3/189/284741




  Introduction Top


On March 11, 2020, the World Health Organization (WHO) declared novel coronavirus disease-19 (COVID-19) outbreak as a pandemic and called for countries to take immediate actions and scale up their responses to detect, reduce transmission, contain, and treat patients to minimize the loss of lives. The COVID-19 pandemic has caused disruption to livelihoods, economies, and health-care systems worldwide.

The WHO dashboard as on May 1, 2020 showed a total of 3,181,642 confirmed cases of COVID-19 and 224,301 reported deaths.[1] COVID-19 has also been reported in almost all states/union territories of India. As on date, India has had about 36,000 recorded cases and approximately 1200 deaths. The lockdown was imposed in India on the March 25, 2020 and is still on. This has kept the transmission of the disease at a low level in India till now. The Government of India has been and is taking all efforts to ensure preparedness to face the challenges and threats posed by this pandemic. Once the lockdown is relaxed, there is likely to be a surge of COVID-19 patients presenting to health-care centers.

The novel SARS-CoV-2 virus has high infectivity, absence of herd immunity, ability to infect through asymptomatic carriers, and has a high morbidity and mortality in vulnerable populations. Hence, each human being needs to take the responsibility of addressing some aspect of this pandemic, so that it can be overcome with minimal morbidity and further mortality. Laypersons, local health authorities, management bodies, association of doctors, government health organizations, private health-care institutions/hospitals/clinics/health care organization (HCO) Directors, administrators, and health-care workers (HCWs), all have very important roles to play. One such role in the private health sector is that of the medical administration which should be able to provide the HCWs a modified system of working which is practical, scientific, appropriate, simple, and safe so that it is possible to follow. It is not certain, how long this pandemic may last and since the pathophysiology of COVID-19 is not clearly understood, advisories and recommendations are likely to be modified. However, there is a place for designing tools, flow charts, and practice guidelines which will continue to serve as a framework for HCOs to standardize their workflow.

The tools and guidelines presented here should enable senior health-care administrators working in private HCOs to create tools for their own institutions based on infrastructure, materials and manpower resources. Personal protective equipment, safety of HCWs, ensuring availability of PPEs, maintaining a high morale among all the workers in the HCO and ensuring crowd control in the campus are not addressed but are presumed to be in place.[2],[3]

A few months after the COVID-19 pandemic had started; the Tamil Nadu State Government health authorities included certain private HCOs in their list of designated COVID-19 hospitals. This suddenly imposed a very great responsibility upon such institutions since they were centers giving treatment to essentially non-COVID-19 patients. Under such circumstances, the need for developing and implementing tools and guidelines were felt necessary for carrying out safe health care.


  Methodology Top


This manuscript covers tools, flow charts, and guidelines related to patient flow, screening, triaging, assigning a severity score, and managing patients in the outpatient and inpatient setting. It focuses upon systems to ease, hasten, and standardize the work of HCWs faced with managing patients with an unfamiliar disease of pandemic proportions.

The method used for this purpose was a literature search on COVID-19, drawing from publications from the WHO, Government of India– Ministry of Health and Family Welfare, NCBI-PubMed indexed journals, up-to-date, as well as manuscripts and videos shared by the clinicians working in high COVID-19 load institutions worldwide. These resources were researched by an experienced physician and anesthesiologist working in different institutions. The findings were discussed over phone, E-mails, and video-chats, and these tools, flowcharts, and guidelines were then developed. They were implemented in a secondary care hospital in Southern India and once the benefits of these protocols were realized, the authors decided to submit this manuscript for the publication.


  Discussion Top


The patient flowchart [Figure 1] gives an overall idea and guide of the system created.[4] The first step is to try and segregate all individuals entering the health-care facility into those having positive screening criteria for COVID-19 from others, so that those with symptoms can be directed to a separate dedicated area of the hospital[2],[5] (dedicated fever clinic) for further management. This can be done using the screening tool[2],[5],[6],[7] [Figure 2].
Figure 1: Patient flowchart during COVID-19 pandemic in a secondary care private hospital.

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Figure 2: COVID-19 – rapid screening form.

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Once the patients are segregated, all those positive on screening are directed to the dedicated fever clinic. All other individuals who are negative at the COVID-19 screening step are sent to the routine OP reception, where vulnerable patients (those with comorbid conditions and the elderly) are shown on priority at the appropriate outpatient clinic with limited time and movement within the hospital. This is done since the morbidity and mortality of COVID-19 are much higher in this group of individuals, and it is prudent not to expose them to the asymptomatic carriers of novel SARS-COV-2 virus. The screening tool [Figure 2] is not good enough to identify all viral carriers, but it may help in at least segregating those who may infect others more easily in spite of social distancing, wearing mask, and observing hand hygiene.

At the dedicated fever, clinic triaging is done by a staff using the triaging tool [Figure 3].[6],[8] The objective is for the patient to be seen early by a HCW, so that priority 1 and 2 patients can be identified and can be shown to the fever clinic doctor urgently. Furthermore, comorbidities, risk factors, and the patient's current medication details can be obtained, thereby saving valuable clinician time.
Figure 3: COVID-19 – triage form.

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The clinician in the dedicated clinic interviews and examines the patient and decides whether he/she is a COVID-19 suspect or not. All non-COVID-19 suspect patients will be directed to the routine outpatient clinics of the institution. The clinician at the dedicated fever clinic then uses the COVID-19 Severity Scoring Tool[9] [Figure 4] for COVID-19 suspects to assign a severity score, which in addition to the clinical examination enables a decision to be made, as to whether the patient should be admitted into a COVID ward, COVID ICU or can be managed at home in isolation as per the [Figure 5] guidelines.[8],[9],[10],[11],[12],[13] All such COVID-19 suspects would be subjected to oropharyngeal and nasopharyngeal swab testing for the virus as per the existing government advisory.[5] To save documentation time of the clinician and to encourage COVID-19 suspect patients to comply with the advice, the OP/home management advise form [Figure 6] is utilized.[4] One form is pasted on the patient's medical record, and a copy is given to the patient.
Figure 4: COVID-19 – severity scoring tool.

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Figure 5: Clinical management guidelines for mild-or-moderate COVID-19.

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Figure 6: COVID-19-outpatient management advice.

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Those patients who are admitted are treated in keeping with the COVID-19 inpatient management guidelines for clinicians, as shown in [Figure 7], i.e., for those with severe disease and those with critical disease.[5],[8],[10],[12],[14],[15],[16],[17],[18] Details on this chart are likely to change and may need modification as and when newer evidence based recommendations are published.
Figure 7: Clinical management guidelines for in-patients with severe or critical COVID-19.

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A simple monitoring chart which can pick up deterioration in the patients is shown in [Figure 8]. This is a “Modified Early Warning Signs” chart which is in use in the institution and is appropriate for COVID-19 patients too.[8]
Figure 8: Modified Early Warning Signs chart.

Click here to view


The authors have included an oxygen therapy flow chart[5],[8] as [Figure 9], as they feel that this precious, life-saving gas can be better utilized if some guidelines are accessible readily.[5],[8]
Figure 9: Algorithm for oxygen therapy in COVID-19.

Click here to view



  Conclusion Top


Particular attention needs to be paid to the delivery of essential healthcare while ensuring the safety of healthcare organizations and their staff. This manuscript has been submitted for publication in the hope that other private HCOs may find it easy to set up a system at their institution during this challenging period of the COVID-19 pandemic.

Acknowledgments

The authors would like to thank Dr. A. D. Jeyasekharan and Dr Shweta Singhal for his technical support and guidance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
COVID-19 India. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 May 02].  Back to cited text no. 1
    
2.
World Health Organization. Infection Prevention and Control During Healthcare when COVID-19 is Suspected. Interim Guidance; 19 March, 2020. Available from: https://www.who.int/publicat ions-detail/infection-preventi on-and-control-during-hea lth-care-when-novel-coron avirus-(ncov)-infection-is-sus pected-20200125. [Last accessed on 2020 May 02].  Back to cited text no. 2
    
3.
World Health Organization. Rational use of Personal Protective Equipment for Coronavirus Disease (COVID-19) and Considerations During Severe Shortages. Interim Guidance; 6 April, 2020. Available from: https://www.who.int/publications-detail/rational-use-of-pe rsonal-protective-equipment-for-coronavirus-disease-(co vid-19)-and-considerations-du ring-severe-shortages. [Last accessed on 2020 May 02].  Back to cited text no. 3
    
4.
IMA TNSB. COVID ERA. Clinician Practicing Guidelines. Available from: https://imatn.com/wp-cont ent/uploads/2020/04/Practic ing%20guidelines.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 4
    
5.
Revised Guidelines on Clinical Management of COVID – 19. EMR Division, Director General of Health Services, MOHFW. Available from: https://www.mohfw.gov.in/pdf/Rev isedNationalClinicalManagementGuidelineforCOVID1931032020.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 5
    
6.
Seshadri MS, John TJ. The COVID-19 pandemic: Defining the clinical syndrome and describing an empirical response. Christian J Global Health 2020;7:37-44.  Back to cited text no. 6
    
7.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) available from: https://www.cdc.gov/coronavir us/2019-ncov/symptoms-testing/sympto ms.html. [Last accessed on 2020 May 01].  Back to cited text no. 7
    
8.
World Health Organization. Clinical Management of Severe Acute Respiratory Infection (SARI) when COVID-19 Disease is Suspected. Interim Guidance; 13 March 2020. Available from: https://www.who.int/public ations-detail/clinical-manage ment-of-severe-acute-res piratory-infection-when-no vel-coronavirus-(ncov)-infecti on-is-suspected. [Last accessed on 2020 May 02].  Back to cited text no. 8
    
9.
COVID-19 Severity Scoring Tool. Available from: https://surgisphere.com/resea rch-tools/seve rity.php. [Last accessed on 2020 May 02].  Back to cited text no. 9
    
10.
NIH COVID-19 Treatment Guidelines. Available from: https://covid19treatmentgui delines.nih.gov/overview/mana gement-of-covid-19/. [Last accessed on 2020 May 02].  Back to cited text no. 10
    
11.
Guidelines for Home Quarantine. EMR Division, Director General of Health Services, MOHFW. Available from: https://www.mohfw.gov.in/pdf/Guideli nesforhomequ arantine.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 11
    
12.
Foxman EF, Storer JA, Fitzgerald ME, Wasik BR, Hou L, Zhao H, et al. Temperature-dependent innate defense against the common cold virus limits viral replication at warm temperature in mouse airway cells. Proc Natl Acad Sci U S A 2015;112:827-32.  Back to cited text no. 12
    
13.
Hobday RA, Dancer SJ. Roles of sunlight and natural ventilation for controlling infection: Historical and current perspectives. J Hosp Infect 2013;84:271-82.  Back to cited text no. 13
    
14.
Grant WB, Lahore H, McDonnell SL, Baggerly CA, French CB, Aliano JL, et al. Evidence that vitamin D supplementation could reduce risk of influenza and COVID-19 infections and deaths. Nutrients 2020;12:988.  Back to cited text no. 14
    
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Coronavirus Disease 2019 (COVID-19): Critical Care Issues. Available from: https://www.uptodate.com/cont ents/coronavirus-dise ase-2019-covid-19-critical-care-issues#H1056128993(). [Last accessed on 2020 May 02].  Back to cited text no. 15
    
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Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020;18:1023-6.  Back to cited text no. 16
    
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Liu J, Liu Y, Xiang P, Pu L, Xiong H, Li C, et al. Neutrophil-to-lymphocyte ratio predicts severe illness patients with 2019 novel coronavirus in the early stage. 2020. doi.org/10.1101/2020.02.10.20021584.  Back to cited text no. 17
    
18.
World Health Organization. Home Care for Patients with COVID-19 Presenting with Mild Symptoms and Management of their Contacts. Interim Guidance; 17 March, 2020. Available from: https://www.who.int/publ ications-detail/home-car e-for-patients-with-suspect ed-novel-coronavirus-(ncov)-infection-presenting-with-m ild-symptoms-and-managemen t-of-contacts. [Last accessed on 2020 May 02].  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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