Quarantine and isolation

Quarantine and Isolation are important mainstay of cluster containment. These measures help by breaking the chain of transmission in the community.

Quarantine

Separation of individuals who are not yet ill but have been exposed to COVID-19 and therefore have a potential to become ill. There will be voluntary home quarantine of contacts of suspect /confirmed cases.

Isolation

Separation of individuals who are ill and suspected or confirmed of COVID-19. All suspect cases will be hospitalized and kept in isolation till such time they are tested negative.

Persons testing positive for COVID-19 will remain to be hospitalized in Isolation till such time 2 of their samples are tested negative as per MoHFW’s discharge policy.

Ideally, patients can be isolated in individual isolation rooms or negative pressure rooms with 12 or more air-changes per hour.

Resource constrained settings –

1. Non-availability of negative pressure rooms – ensure proper cleaning protocol;
2. Non-availability of single rooms – use ward with good ventilation, minimum distance of 1 meter between beds;

All such patients need to wear a triple layer surgical mask at all times.

An IPC (Infection Prevention Committee) should be formed (if not already in place).

The hospitals will ensure that all healthcare staff is trained in washing of hands, respiratory etiquettes, donning/doffing & proper disposal of PPEs and bio-medical waste management.

Setting up isolation facility/ward (Minimum 10 beds)

1. Ensure adequate signage.
2. Remove all non-essential furniture.
3. Minimum space of 2000 sq. feet.
4. Should have a separate entry/exit and should not be co-located with post-surgical wards/dialysis unit/SNCU/labour room etc.
5. It should be in a segregated area which is not frequented by outsiders.
6. The access to isolation ward should be through dedicated lift/guarded stairs.
7. Double door entry with changing room and nursing station.
8. Used PPEs should be disposed as per the BMWM guidelines.
9. Stock the PPE supply and linen outside the isolation room or area (e.g. in the change room). Setup a trolley outside the door to hold PPE.
10. Use a touch-free bin. Ensure that used (i.e. dirty) bins remain inside the isolation rooms.
11. Puncture-proof container for sharps disposal inside the isolation room/area.
12. Keep water pitchers and cups, tissue wipes, and all items necessary for attending to personal hygiene within the patient’s reach.
13. Patients are strictly not to be allowed use of mobile phones or PEDs
14. Non-critical patient-care equipment (e.g. stethoscope, thermometer, blood pressure cuff, and sphygmomanometer) should be dedicated for the patient.
15. Ensure that appropriate hand washing facilities and hand-hygiene supplies are available. Stock the sink area with suitable supplies for hand washing, and with alcohol-based hand rub, near the point of care and the room door.
16. Ensure adequate room ventilation. If room is air-conditioned, ensure 12 air changes/ hour and filtering of exhaust air. These rooms may have standalone airconditioning. These areas should not be a part of the central air-conditioning.
17. If air-conditioning is not available negative pressure could also be created through putting up 3-4 exhaust fans driving air out of the room.
18. Natural ventilation may be followed. Such isolation facility should have large windows on opposite walls of the room allowing a natural unidirectional flow and air changes.
19. The isolation ward should have a separate toilet with proper cleaning and supplies.
20. Avoid sharing of equipment, but if unavoidable, ensure that reusable equipment is appropriately disinfected between patients.
21. Visitors to the isolation facility should be restricted /disallowed. For unavoidable entries, with prior permission of the Physician In-charge, they should use PPE according to the hospital guidance, and should be instructed on its proper use and in hand hygiene practices prior to entry into the isolation room/area.
22. Doctors, nurses and paramedics posted to isolation facility need to be dedicated and not allowed to work in other patient-care areas.
23. Consider having designated portable X-ray and portable ultrasound equipment.
24. Ideally, the HCW should not leave the room during his/her shift of work.

Checklist for isolation rooms

1. Eye protection (visor or goggles)
2. Face shield (provides eye, nose and mouth protection)
3. Gloves
4. Reusable vinyl or rubber gloves for environmental cleaning
5. Latex single-use gloves for clinical care
6. Hair covers
7. Particulate respirators (N95, FFP2, or equivalent)
8. Medical (surgical or procedure) masks
9. Gowns and aprons
10. Single-use long-sleeved fluid-resistant or reusable non-fluid-resistant gowns
11. Plastic aprons (for use over non-fluid-resistant gowns if splashing is anticipated and if fluid-resistant gowns are not available)
12. Alcohol-based hand rub
13. Plain soap (liquid if possible, for washing hands in clean water)
14. Clean single-use towels (e.g. paper towels)
15. Sharps containers
16. Appropriate detergent for environmental cleaning and disinfectant for disinfection of surfaces, instruments or equipment
17. Large plastic bags
18. Appropriate clinical waste bags
19. Linen bags
20. Collection container for used equipment
21. Standard IEC
22. Standard protocols for hand hygiene, sample collection and BMW displayed clearly
23. Standard Clinical management protocols

Wearing and removing Personal Protective Equipment (PPE)

Before entering the isolation room or area:

• Collect all equipment needed;
• Perform hand hygiene with an alcohol-based hand rub (preferably when hands are not visibly soiled) or soap and water (when visibly soiled);
• Put on PPE in the following order – cap - shoe cover – hand hygiene – inner glove – gown – mask – glasses - face/neck shield - outer gloves;

Leaving the isolation room or area: (allowed only at the end of duty hours; the duty hours will not be more than 6 hrs shift):

• Remove PPE outside the Isolation ward and the Anteroom where you donned it;
• Order of removal of PPE – Outer Gloves - hand hygiene – gown - shoe cover – glasses - face/neck shield-mask-cap – inner gloves - hand hygiene. Put reusable items in a separate dry bin.

Transport of Infectious Patients

It is recommended that transport of infectious patients is limited to movement considered medically essential by the clinicians.

1. Inform the destination unit
2. Send out information to keep the passage free from any other person
3. Ensure that the lift, if needed, is stationery on the floor
4. Cover the infected or colonised areas of the patient’s body.
5. Use the patient’s bed for transport, avoiding unnecessary transfers. Put the patient on full PPE. Isolator, if available, would be a good alternative; the patient can be slid into the isolator
6. The transport personnel will remove existing PPE, cleanse hands, put on clean PPE and transport the patient.
7. A combination of nominated lifts, corridors and a bed transfer floor would assist in the movement of infectious patients through the hospital and minimise the risk of spread of infection.

Check list (abridged)

1	Rapid Response Team identified?
2	Contingency plan for covering for a core team member who is absent?
3	Training for Healthcare Personnel (HCP)
4	• Signs and symptoms of infection
5	• Triage procedures including patient placement
6	• Safely collect clinical specimen
7	• Correct infection control practices and PPE use
8	• Recommended actions for not using recommended PPE
9	• How and to whom suspected cases (COVID-19)should be reported
10	Triage protocols available at the healthcare facility?
11	Availability of telemedicine facility?
12	Is there a specific “Fever Clinic”?
13	Availability of designated COVID-19 triage area?
14	Non-contact Infra-Red thermometer available?
15	Availability of signage directing to triage area?
16	Dedicated/single examination rooms in Triage area?
17	Triage area has signs/alerts about respiratory etiquette and hand hygiene?
18	Does the HCF provide masks for patients with respiratory symptoms?
19	Waste bins and access to cleaning/ disinfection supplies available in Triage area
20	Physical barriers (e.g., glass or plastic screens) at reception areas available?
21	Waiting area cleaned at least twice daily with 0.5% hypochlorite solution (or) 70% alcohol for surfaces that do not tolerate chlorine
22	Are washrooms available as 1 toilet per 20 persons?
23	Do the hospital have policy to segregate clinical staff (e.g. nurses) for care of Covid 19 cases
24	For a patient on Airborne Precautions, air pressure is monitored daily with visual indicators (e.g., smoke tubes, flutter strips), regardless of the presence of differential pressure sensing devices (e.g., manometers)
25	Is there an ICU facility attached to isolation area?
26	Is there any designated area for sample collection?
27	Are they following standard precautions and PPE while taking sample?
28	Are these sample transported in triple packing?
29	Are the floors of isolation facility suitable for moping?
30	Is drinking water available at isolation area?
31	Does the hospital have Hospital Infection control Committee (HICC)?
32	Are there any infection control protocols/guidelines available?
33	Functioning hand washing stations (including water, soap and paper towel or air dry) at isolation area?
34	Is there cleaning chart?
35	Is the oxygen supply is by cylinder or central connection?
36	Are there any separate Ventilators, nebulizers, Infusion pumps in ICU?
37	Designated ambulance facility for transporting patients from isolation area?
38	Ambulance staff trained in wearing PPE & and other Infection control practices?
39	SOP for disinfecting ambulance after transporting confirmed case/dead body?