GUIDELINE FOR BULE HORA

GENERAL HOSPITAL ON THE

CLINICAL MANAGEMENT OF
CORONA /COVID-19

MARCH 20,2020

THIS TRAINING MANUAL WAS PREPARED BY NATIONAL DMAT. February 07, 2020
 Contents
BACKGROUN
D
INTRODUCTION
PREHOSPITAL CASE MANAGMENT
IPC MEASUERS
PP EQUIPMENTS
TRIAGES AND TREATMENT FORMAT FOR COVID-19
EMERGENCY DEPARTMENT MANAGMENT
PATIENT FLOW
CASE MANAGMENT
EQUIPMENT REQUIRED
ICU SETUP
 ADMISSION CRITERIAS

BACKGROUND

Bule Hora General Hospital was established in 1990 e.c located in Bule Hora town
468km from capital city in the southern direction. The Climate is Weyna Dega
and has an altitude of 1716 meters above sea level.

Initially it was estimated to serve over 2.5 million people living in West Gujii,
Gujii and Borana zone of Oromia regional state. Currently due to establishment
of different hospitals in the stated zones the catchment population has dropped
to about 1.3 million of people.
The hospital has different clinical departments and services including general
surgery, obstetrics and Gynecology, Pediatrics and child health, Adult Medicine,
MDR and TB treatment center, ART clinic, Eye clinic, Cervical CA screening, Burn
Unit, Neonatal ICU, Psychiatry clinic, Private wing clinic, ETAT, Dental clinic,
Laboratory and radiology services, regular and emergence services for adult and
pediatric as outpatient.

Our hospital is also delivering service as excellence center in oromia region

particularly Guji-Borena zone for BURN CENTER, TERITARY LEVEL NICU and
INSERVICE TRAINING CENTER.

The quality unit details the approach to quality improvement that our hospital
GB and SMT through its CG & QIU are taking over the end of 2012 e.c in order
for us to see healthy, productive and prosperous community and being the
service of choice for those who need good quality of care. Our success of good
quality service delivery and utilizes our existing culture of innovation and
continuous improvement. It details the approach to quality improvement both
for clinical quality improvement and also for quality improvement in our
nonclinical services that provide services to our customers (usually patients and
their relatives, our government agencies, clinical and managerial staff and to
reduce morbidity, mortality, disability and improve the health status of
catchment population through provision of quality curative and rehabilitative
health services, and bring comprehensive package of prevention closely to our
community.

EMERGENCY RESPONSE TEAM of our hospital has 35 members from different

service provision areas with responsibility to ensure rapid response on mass
causality, disaster, epidemic and pandemic disease management each
members of the team are assigned with official letters.
Introduction
Severe acute respiratory infection remains one of the leading causes of mortality
around the world. A recent cluster of pneumonia cases in Wuhan, China, was
caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). It
has been recognized as global public health emergency by WHO after cases had
started to be seen outside china. Ethiopia is listed by WHO under countries with
high risk of acquiring the infection due to frequent flight from affected area.
This will further worsen countries situation to handle the burden once case is
identified. It is critical that countries step up their readiness and in particular put
in place effective screening mechanisms at airports and other major points of
entry. (WHO)
After the report of the first case in Wuhan City, Hubei Province, China on
December 31, 2019, new cases are being reported from different area around the
world. Resulting in, 31,481 confirmed cases and 638 deaths to date. (7th
Feb2020, CDC). To minimize the exposure to and transmission of 2019-ncov,
infection prevention and control measures should be implemented systematically
based on the standard, contact, and droplet precautions. Effective initial
screening of patients by visual triaging has a crucial role in isolating patients
that can potentially transmit infections to other patients or healthcare
professionals.
This treatment guideline encompasses principles of infection prevention and
control, starting from the scene up to patient discharge and safe burial system if
patient died. Management of critically ill patients, in wards and ICU has been
discussed as per guideline. Ethical considerations regarding safety of health
professionals and bioethics have been included. Due to limited information
available about 2019-nCoV regarding the diagnosis, duration of shedding,
disease severity and transmission, the guide line will be revised and updated as
more information becomes available. All healthcare facilities must ensure that
health professionals are well trained and able to implement infection control
procedures and disease management.
Pre- hospital case management

EOC, Emergency dispatch: Pre hospital emergency care involves activation of

the EOC or Dispatch center, and these centers should have three digit or four
digit communication devices for the public access and cell phones or Walky-
talky for communication with ambulance crew. Health education on how, when
to use this communication system should give regularly and continuously.The
EOC pre-hospital focal person or the dispatcher completes the dispatch
documentation using pre prepared format and if the information given fulfills
the case definition, he/she contacts the BLS or ALS ambulance crew according
the severity of case, and gives order where to take the case, and subsequently
informs the receiving health facility on the incoming suspect or case. The EOC
should have separate dedicated ambulances for the cases, and equip the
ambulances with IPC, supportive and resuscitation equipment and supplies
according the ambulance level and IPC protocol.
Ambulance crew:The ambulance crew, maintains PPE&IPC, at all times,
(before, during and after handling of cases or suspects). Conducts triage and
treatment at the scene and during transportation. Every care and treatment given
should be documented on the triage &treatment format, when necessary he/she
should contact the designated receiving health facility for help or to update the
condition of the case. Finally the ambulance crew should handover patients with
verbal and written communication and maintains documents properly and report
as per the national guideline. When suspected patient is transported to
quarantine or designated hospital the hand over should be with precaution so, for
this purpose:

 Pre arrival communication should made, then

 well prepared with use of PPE, staff approaches the ambulance
 patient handover with verbal & written document
 ambulance crew remains in the ambulance
  proper discard or disinfect all used PPE (mask, gown, face or eye covers,
gloves )before going out of ambulance
 disinfect the ambulance
Triage: use PPE at all times.Give suspect or patient a medical mask and when
there is more than one suspectdirect patient to separate area, an isolation room if
available. Keep at least 1 meter distance between suspected patients and other
patients. Instruct all patients to cover nose and mouth during coughing or
sneezing with tissue or flexed elbow for others. Perform hand hygiene after
every contact with respiratory secretions.
Transportation: Prepare ambulance equipment for every shift and following
every use, handle equipment according IPC, Check Equipment using checklist
following every use, Continue patient treatment and care during transportation
and Handover to receiving institution with Verbal and Written format.
Governance: at the EOC there should be a prehospital focal person that lead
and monitor the activities are going according the guideline.
M& D: all cases handled with suspicion of corona virus will have proper
documentation at all level; (dispatch or EOC, ambulance service)and handover
to health facilities. 24hrs activity report will be submitted to the pre hospital
EOC focal person
IPC measures

1. Hand hygiene according IP protocol (use hand sanitizer before and after
touching of cases, hand washing with soup for at least 20min), avoid
touching doors, equipment, with used gloves
2. Proper uses of PPE –
2.1 Droplet precautions: Use a medical mask if working within 1-2
meters of the patient. Place patients in single rooms, or group together those
with the same etiological diagnosis. If an etiological diagnosis is not
possible, group patients with similar clinical diagnosis and based on
epidemiological risk factors, with a spatial separation. When providing care
in close contact with a patient with respiratory symptoms (e.g. coughing or
sneezing), use eye protection (face-mask or goggles), because sprays of
secretions may occur. Limit patient movement within the institution and
ensure that patients wear medical masks when outside their rooms.
 2.2 Airborne precautions:when performing an aerosol generating
procedure; i.e. open suctioning of respiratory tract, Intubation, CPR) use
PPE, including gloves, long-sleeved gowns, eye protection, and N95.
2.3 Contact precautions: transmission from contact with contaminated
surfaces or equipment (i.e. contact with contaminated oxygen
tubing/interfaces). Use PPE (medical mask, eye protection, gloves and
gown) when entering room/ambulance and remove PPE when leaving. If
possible, use either disposable or 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. Ensure that
you and your colleagues refrain from touching eyes, nose, and mouth with
potentially contaminated gloved or ungloved hands. Avoid contaminating
environmental surfaces that are not directly related to patient care (e.g. door
handles and light switches). Ensure adequate room/ambulance ventilation.
Avoid movement of patients or transport. Perform hand washing regularly.
3. Disinfection of reusable contaminated materials
3.1 Disinfect reusable equipment’s such as Bag Valve Mask, Laryngoscop,
magil forceps, BP apparatus with 10% sedexberekina
3.2 Cover o2 cylinder and gage with plastic and dispose after every use in
collecting bag
 3.3 Disinfect the ambulance with chemical spray and ventilate

4. waste management
4.1 There should be waste disposal center for every contaminated material
4.2 keep every contaminated material in plastic bag
4.3 keep sharp materials separate in safety box
4.4 Disinfect and clean the ambulance after every use
PP equipment

Item Purpose How to use How/ when to

dispose

N 95 Droplet infection 1for every

mask prevention case

Safety Droplet infection 1for every

Goggle prevention case
Plastic Droplet infection 1for every
Face prevention case
shield

Isolation Prevention from 1for every

gown body fluids case

Surgical Prevention from 1for every

head secretion of body case
cover fluids

Boots Prevention from Disinfect

body fluids

Surgical Prevention from 1for every

glove body fluids case
Hand Prevention of
sanitizer cross infection

Safety
box

Waste
disposal
plastic

Waste
disposal
points

Supportive &Resuscitation equipment &supplies

Item Specification Quantity How to handle
&dispose

O2 cylinder 2for each

ambulance

O2 gage 2for each

ambulance

O2 flow 2for each

meter ambulance

O2 delivery 10,000
face mask

O2 delivery 10,000
nasal
cannula

Ambu bag 2for each Some Ambu

(BVM) ambulance bags can be
different sterilized in an
size, with autoclave at
different 134° C or 272°
face masks F. Otherwise,
it must be
sterilized
through the
use of the
recommended
disinfectant s
olution.
Glutaraldehyd
e 2% is an
appropriately
high-level disi
 nfectant;
the bag must
be immersed
in the solution
for at least 20
minutes.

NIV- 2for each Recommende

CPAP/BiP ambulance d disinfectant
AP with solution.
tight feting Glutaraldehyd
mask e2% is an
&strips appropriately
high-level disi
nfectant; at
least 20
minutes.
Manual/ 2for each
electrical ambulance
suction
machine

Suction 10,000 Discard

tube
different
size

Transportat 2for each

ion MV ambulance

Oro- 10,000 Recommende

pharyngeal d disinfectant
airway solution.
Glutaraldehyd
e 2% is an
 appropriately
high-level disi
nfectant;at
least 20
minutes.

Naso- 10,000 recommended

pharyngeal disinfectant s
airway olution.
Glutaraldehyd
e 2% is an
appropriately
high-level disi
nfectant;at
least 20
minutes.

Automated 2for each Clean after

ECG every use the
monitor ambulance surface using
with(BP,P, antiseptics
Sao2, ECG,
ECO2,
T,RR)

Laryngosco 2 box for each

p with ambulance
different
size blades

ETT 1000
different
size

Bugi 2for each

ambulance
Stylet 2for each
ambulance

Adhesive 2for each

plaster ambulance

Bandage 2 packs for each

ambulance

Gauze 2 packs for each

ambulance

Syringe 20 for each

different ambulance
size
IV canola 20 for each
ambulance

Antipyretic
drugs

Triage and treatment format suspected of 2019-nCoV infection

1. Date …………., time…………… service given

2. Name of the patient …………………………………….
3. Age ………………., sex……………………….
4. Does the patient have acute respiratory infection symptoms? Yes…….,
no……
5. If yes select from the listed below
4.1 Fever,
4.2 Cough,
4.3 sneezing
6. Does the patient have travel history? Yes………, No…….., If yes

a. Close contact with a confirmed or probable case of 2019-nCoV in the

14 days prior to illness onset, Yes …………….,
No…………………..
b. visiting or working in a live animal market in Wuhan, Hubei
Province, China in the 14 days prior to symptom onset,
Yes……………….., No………………
c. Worked or attended a health care facility in the 14 days prior to onset
of symptoms where patients with hospital associated 2019-nCov
infections has been reported.
7. Suspect corona virus with any acute respiratory illness AND at least one of
the above
8. Apply all IPC precautions for corona virus
9. VS: BP……………………, P……………….., RR…………………,
Sao2………………, T………………,
10. Treatmentgiven…………………………………………………………
………………………………………………………………………………
………………………………………………………………………………
 ………………………………………………………………………………
…………………………………………………………..
11. Pre arrival call to receiving institution: yes …………………,
No……………….
12. Time ………..and date …………………..transfer to
……………………..health facility/ quarantine area
13. Handover by ………………………………, signature ………………..
14. Accepted by …………………………………….., signature …………….

Emergency department management

PATIENT FLOW
1.1 Non Quarantine health facility ED
1.1.2 Pre triage screening :
 Pre triage screening area: Recognize and sort all patients with
SARI at first point of contact with health care system and Consider
nCOV as a possible etiology of SARI under certain conditions (see
Table 1). Follow the algorithm 1 for every patient.
 Every health facility should have a pre triage screening area to
screen out basic things with history while taking vital sign and feel
up a proper format.( format should be prepared and available in each
facility)
 Immediate implementation of appropriate 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. Standard precautions should always be
routinely applied in all areas of health care facilities. Standard
precautions include hand hygiene; use of PPE to avoid direct
contact with patients’ blood, body fluids, secretions (including
respiratory secretions) and non-intact skin. Standard
precautions also include prevention of needle-stick or sharps
injury; safe waste management; cleaning and disinfection of
equipment; and cleaning of the environment.
 At pre-triage screening area give suspect patient a medical mask
and direct patient to an isolation room. Keep at least 1 meter
 distance between suspected patients and other patients. Instruct
all patients to cover nose and mouth during coughing or
sneezing with tissue or flexed elbow for others. Perform hand
hygiene after contact with respiratory secretions.

 Design of the area

 Equipment for this area
 Human capacity and dressing code

SARI

An ARI with history of fever or measured temperature ≥38 C° and

cough; onset within the last ~10 days; and requiring
hospitalization.5 However, the absence of fever does NOT exclude
viral infection.6
 A. Patients with severe acute respiratory infection (fever, cough,
and requiring admission to hospital), AND with no other etiology
that fully explains the clinical presentation1 AND at least one of
the following:
 A history of travel to or residence in the city of Wuhan, Hubei
Province, China in the 14 days prior to symptom onset, or
 Patient is a health care worker who has been working in an
Surveillance environment where severe acute respiratory infections of
case unknown etiology are being cared for.
definitions
for 2019- B. Patients with any acute respiratory illness AND at least one of
nCoV* the following:
 Close contact2 with a confirmed or probable case of 2019-
nCoV in the 14 days prior to illness onset, or
 Visiting or working in a live animal market in Wuhan, Hubei
Province, China in the 14 days prior to symptom onset, or
 Worked or attended a health care facility in the 14 days prior to
onset of symptoms where patients with hospital-associated
2019-nCov infections have been reported.
 Table 1. Definitions of patients with SARI, suspected of nCoV*
1. Testing should be according to local guidance for management of community-
acquired pneumonia. Examples of other etiologies include Streptococcus
pneumoniae, Haemophilus influenza type B, Legionella pneumophila, other
recognized primary bacterial pneumonias, influenza viruses, and respiratory
syncytial virus.
2. Close contact’ is defined as:
 Health care associated exposure, including providing direct care for nCoV
patients, working with health care workers infected with nCoV, visiting
patients or staying in the same close environment of a nCoV patient.
 Working together in close proximity or sharing the same classroom
environment with a with nCoV patient
 Traveling together with nCoV patient in any kind of conveyance
 Living in the same household as a nCoV patient
 The epidemiological link may have occurred within a 14-day period before
or after the onset of illness in the case under consideration.
1.1.3 Isolation Triage at non quarantine hospital
 Triage the patient and start treatment based on the severity (refer to early
supportive therapy monitoring) while calling for PHEM for transporting
the suspected patient and close contact to Quarantine areas.
 Dead body ?????

Table 2. Clinical syndromes associated with nCoV infection

Uncomplic Patients with uncomplicated upper respiratory tract viral infection, may
ated have non-specific symptoms such as fever, cough, sore throat, nasal
illness congestion, malaise, headache, muscle pain or malaise. The elderly and
immunosuppressed may present with atypical symptoms. These
patients do not have any signs of dehydration, sepsis or shortness of
breath.
Mild Patient with pneumonia and no signs of severe pneumonia.
pneumoni Child with non-severe pneumonia has cough or difficulty breathing +
a fast breathing: fast breathing (in breaths/min): <2 months, ≥60; 2–11
months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia.
Severe Adolescent or adult: fever or suspected respiratory infection, plus one
pneumoni of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2
a <90% on room air (adapted from [1]).
Child with cough or difficulty in breathing, plus at least one of the
following: central cyanosis or SpO2 <90%; severe respiratory distress
(e.g. grunting, very severe chest indrawing); signs of pneumonia with a
general danger sign: inability to breastfeed or drink, lethargy or
unconsciousness, or convulsions. Other signs of pneumonia may be
present: chest indrawing, fast breathing (in breaths/min): <2 months,
≥60; 2–11 months, ≥50; 1–5 years, ≥40.2 The diagnosis is clinical;
chest imaging can exclude complications.
Acute Onset: new or worsening respiratory symptoms within one week of
Respirator known clinical insult.
y Distress Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral
Syndrome opacities, not fully explained by effusions, lobar or lung collapse, or
7-9 nodules.
Origin of oedema: respiratory failure not fully explained by cardiac
failure or fluid overload. Need objective assessment (e.g.
echocardiography) to exclude hydrostatic cause of oedema if no risk
factor present.
Oxygenation (adults):
• Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or
CPAP ≥5 cmH2O,7 or non-ventilated8)
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP
≥5 cmH2O,7 or non-ventilated8)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O,7 or
non-ventilated8)
• When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS
(including in non-ventilated patients)
Oxygenation (children; note OI = Oxygenation Index and OSI =
Oxygenation Index using SpO2):
 • Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤
300 mmHg or SpO2/FiO2 ≤264
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI <
12.3
• Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Sepsis Adults: life-threatening organ dysfunction caused by a dysregulated

host response to suspected or proven infection, with organ
dysfunction*. Signs of organ dysfunction include: altered mental
status, difficult or fast breathing, low oxygen saturation, reduced urine
output, fast heart rate, weak pulse, cold extremities or low blood
pressure, skin mottling, or laboratory evidence of coagulopathy,
thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.
Children: suspected or proven infection and ≥2 SIRS criteria, of which
one must be abnormal temperature or white blood cell count.
Septic Adults: persisting hypotension despite volume resuscitation, requiring
shock vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2
mmol/L.
Children (based on [12]): any hypotension (SBP <5th centile or >2 SD
below normal for age) or 2-3 of the following: altered mental state;
tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and
HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2
sec) or warm vasodilation with bounding pulses; tachypnea; mottled
skin or petechial or purpuric rash; increased lactate; oliguria;
hyperthermia or hypothermia.

Abbreviations: ARI, acute respiratory infection; BP, blood pressure; bpm,

beats/minute; CPAP, continuous positive airway pressure; FiO2, fraction of
inspired oxygen; MAP, mean arterial pressure; NIV, noninvasive ventilation;
OI, Oxygenation Index; OSI, Oxygenation Index using SpO2; PaO2, partial
pressure of oxygen; PEEP, positive end-expiratory pressure; SBP, systolic blood
pressure; SD, standard deviation; SIRS, systemic inflammatory response
syndrome; SpO2, oxygen saturation. *If altitude is higher than 1000m, then
correction factor should be calculated as follows: PaO2/FiO2 x Barometric
pressure/760.
* The SOFA score ranges from 0 to 24 and includes points related to 6 organ
systems: respiratory (hypoxemia defined by low PaO2/FiO2), coagulation (low
platelets), liver (high bilirubin), cardiovascular (hypotension), central nervous
system (low level of consciousness defined by Glasgow Coma Scale), and renal
(low urine output or high creatinine).
Sepsis is defined by an increase in the Sequential [Sepsis-related] Organ Failure
Assessment (SOFA) score13 of ≥2 points. Assume the baseline score is zero if
data are not available.

Table 3. How to implement infection prevention and control measures for

patients with suspected or confirmed nCoV infection

Apply Droplet precautions prevent large droplet transmission of

droplet respiratory viruses. Use a medical mask if working within 1-2
precautions metre s of the patient. Place patients in single rooms, or group
 together those with the same etiological diagnosis. If an
etiological diagnosis is not possible, group patients with similar
clinical diagnosis and based on epidemiological risk factors,
with a spatial separation. When providing care in close contact
with a patient with respiratory symptoms (e.g. coughing or
sneezing), use eye protection (face-mask or goggles), because
sprays of secretions may occur. Limit patient movement within
the institution and ensure that patients wear medical masks when
outside their rooms.
Apply Droplet and contact precautions prevent direct or indirect
contact transmission from contact with contaminated surfaces or
precautions equipment (i.e. contact with contaminated oxygen
tubing/interfaces). Use PPE (medical mask, eye protection,
gloves and gown) when entering room and remove PPE when
leaving. If possible, use either disposable or 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. Ensure that health
care workers refrain from touching their eyes, nose, and mouth
with potentially contaminated gloved or ungloved hands. Avoid
 contaminating environmental surfaces that are not directly
related to patient care (e.g. door handles and light switches).
Ensure adequate room ventilation. Avoid movement of patients
or transport. Perform hand hygiene.
Apply Ensure that healthcare workers performing aerosol-generating
airborne procedures (i.e. open suctioning of respiratory tract,
precautions intubation, bronchoscopy, cardiopulmonary resuscitation)
when use PPE, including gloves, long-sleeved gowns, eye protection,
performing and fit-tested particulate respirators (N95 or equivalent, or
an aerosol higher level of protection). (The scheduled fit test should not be
generating confused with user seal check before each use.) Whenever
procedure possible, use adequately ventilated single rooms when
performing aerosol-generating procedures, meaning negative
pressure rooms with minimum of 12 air changes per hour or at
least 160 litres/second/patient in facilities with natural
ventilation. Avoid the presence of unnecessary individuals in the
room. Care for the patient in the same type of room after
mechanical ventilation commences
Remark: Any suspected case identified within the hospital should be given a
medical mask and immediately evacuate the patient to an isolation room. Keep
at least 1meterdistance between suspected patients and other patients. Instruct all
patients to cover nose and mouth during coughing or sneezing with tissue or
flexed elbow for others. Perform hand hygiene after contact with respiratory
secretions.

1.2 Quarantine health facilities

1.2.1 Reception area

 Continue the treatment initiated elsewhere and re-triage the patient and
dispose to the subsequent areas.
 Mild to moderate to general wards.
 Sever to ICU.
 Dead body to designated morgue

1.2.2 General wards

  Pediatrics
 Adult
 Male
 Female

CASE MANAGEMENT

2.1 Early supportive therapy and monitoring

 Give supplemental oxygen therapy immediately to patients with SARI

and respiratory distress, hypoxaemia, or shock.
Remarks: Initiate oxygen therapy at 5 L/min and titrate flow rates
to reach target SpO2 ≥90% in non-pregnant adults and SpO2 ≥92-
95 % in pregnant patients.1,2 Children with emergency signs
(obstructed or absent breathing, severe respiratory distress, central
 cyanosis, shock, coma or convulsions) should receive oxygen
therapy during resuscitation to target SpO2 ≥94%; otherwise, the
target SpO2 is ≥90%. Use contact precautions when handling
contaminated oxygen interfaces of patients with nCoV infection.
 Use conservative fluid management in patients with SARI when there
is no evidence of shock.
Remarks: Patients with SARI should be treated cautiously with
intravenous fluids, because aggressive fluid resuscitation may
worsen oxygenation, especially in settings where there is limited
availability of mechanical ventilation.16
 Give empiric antimicrobials to treat all likely pathogens causing SARI.
Give antimicrobials within one hour of initial patient assessment for
patients with sepsis.
Remarks: Although the patient may be suspected to have nCoV,
administer appropriate empiric antimicrobials within ONE hour of
identification of sepsis.17 Empiric antibiotic treatment should be
based on the clinical diagnosis (community-acquired pneumonia,
health care-associated pneumonia [if infection was acquired in
healthcare setting], or sepsis), local epidemiology and
susceptibility data, and treatment guidelines. Empiric therapy
 includes a neuraminidase inhibitor for treatment of influenza when
there is local circulation or other risk factors, including travel
history or exposure to animal influenza viruses.18 Empiric therapy
should be de-escalated on the basis of microbiology results and
clinical judgment.
 Do not routinely give systemic corticosteroids for treatment of viral
pneumonia or ARDS outside of clinical trials unless they are indicated
for another reason.

Remarks: A systematic review of observational studies of

corticosteroids administered to patients with SARS reported no survival
benefit and possible harms (avascular necrosis, psychosis, diabetes, and
delayed viral clearance).19 A systematic review of observational
studies in influenza found a higher risk of mortality and secondary
infections with corticosteroids; the evidence was judged as very low to
low quality due to confounding by indication.20 A subsequent study
that addressed this limitation by adjusting for time-varying confounders
found no effect on mortality.21 Finally, a recent study of patients
receiving corticosteroids for MERS used a similar statistical approach
 and found no effect of corticosteroids on mortality but delayed lower
respiratory tract (LRT) clearance of MERS-CoV.22 Given lack of
effectiveness and possible harm, routine corticosteroids should be
avoided unless they are indicated for another reason. See section 6 for
the use of corticosteroids in sepsis.

 Closely monitor patients with SARI for signs of clinical deterioration,

such as rapidly progressive respiratory failure and sepsis, and apply
supportive care interventions immediately.
Remarks: Application of timely, effective, and safe supportive
therapies is the cornerstone of therapy for patients that develop
severe manifestations of nCoV.
 Understand the patient’s co-morbid condition(s) to tailor the
management of critical illness and appreciate the prognosis.
Communicate early with patient and family.
Remarks: During intensive care management of SARI, determine
which chronic therapies should be continued and which therapies
 should be stopped temporarily. Communicate proactively with
patients and families and provide support and prognostic
information. Understand the patient’s values and preferences
regarding life-sustaining interventions.

1.3 Special considerations for pregnant patients

 Pregnant women with suspected or confirmed nCoV should be treated

with supportive therapies as described above, taking into account the
physiologic adaptations of pregnancy.
 The use of investigational therapeutic agents outside of a research study
should be guided by individual risk-benefit analysis based on potential
benefit for mother and safety to fetus, with consultation from an
obstetric specialist and ethics committee.
 Emergency delivery and pregnancy termination decisions are
challenging and based on many factors: gestational age, maternal
 condition, and fetal stability. Consultations with obstetric, neonatal, and
intensive care specialists (depending on the condition of the mother)
are essential.

2.3 Specific anti-Novel-CoV treatments and clinical research

 There is no current evidence from RCTs to recommend any specific
anti-nCoV treatment for patients with suspected or confirmed nCoV.
 Unlicensed treatments should be administered only in the context
of ethically-approved clinical trials or the Monitored Emergency
Use of Unregistered Interventions Framework (MEURI), with
strict monitoring.
https://www.who.int/ethics/publications/infectious-disease-
outbreaks/en/
 Clinical characterization protocols are available, including the
SPRINT-SARI https://isaric.tghn.org/sprint-sari/ and
WHOISARIC forms available at
https://isaric.tghn.org/protocols/severe-acute-respiratory-infection-
data-tools/. Contact [email protected] for additional questions.
2. COLLECTION OF SPECIMENS FOR LABORATORY
DIAGNOSIS ( to be revised by laboratory)

WHO guidance on specimen collection, processing, and

laboratory testing, including related biosafety procedures, is
available.
 Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally
before antimicrobial therapy. DO NOT delay
antimicrobial therapy to collect blood cultures.
 Collect specimens from BOTH the upper respiratory tract (URT;
nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT;
expectorated sputum, endotracheal aspirate, or broncho-alveolar lavage) for
nCoV testing by RT-PCR. Clinicians may elect to collect only LRT samples
when these are readily available (for example, in mechanically ventilated
patients).
 Serology for diagnostic purposes is recommended only when RT-PCR is
not available.

Remarks: Use appropriate PPE for specimen collection (droplet and

contact precautions for URT specimens; airborne precautions for LRT
specimens). When collecting URT samples, use viral swabs (sterile
Dacron or rayon, not cotton) and viral transport media. Do not sample
the nostrils or tonsils. In a patient with suspected novel coronavirus,
especially with pneumonia or severe illness, a single URT sample does
not exclude the diagnosis, and additional URT and LRT samples are
recommended.23 LRT (vs. URT) samples are more likely to be positive
and for a longer period.23 Clinicians may elect to collect only LRT
samples when these are readily available (for example, in mechanically
ventilated patients). Sputum induction should be avoided due to
increased risk of increasing aerosol transmission.
Remarks: Dual infections with other respiratory viral infections have
been found in SARS and MERS cases. At this stage we need detailed
microbiologic studies in all suspected cases. Both URT and LRT
specimens can tested for other respiratory viruses, such as influenza A
and B (including zoonotic influenza A), respiratory syncytial virus,
 parainfluenza viruses, rhinoviruses, adenoviruses, enteroviruses (e.g.
EVD68), human metapneumovirus, and endemic human coronaviruses
(i.e. HKU1, OC43, NL63, and 229E). LRT specimens can also be
tested for bacterial pathogens, including Legionella pneumophila.
 In hospitalized patients with confirmed nCoV infection, repeat URT and LRT
samples should be collected to demonstrate viral clearance. The frequency of
specimen collection will depend on local circumstances but should be at least
every 2 to 4 days until there are two consecutive negative results (both URT
and LRT samples if both are collected) in a clinically recovered patient at
least 24 hours apart. If local infection control practice requires two negative
results before removal of droplet precautions, specimens may be collected as
often as daily.

Equipment required in the treating areas

 All areas where patients with SARI are cared for should be equipped
with pulse oximeters, functioning oxygen systems and disposable,
single-use, oxygen-delivering interfaces (nasal cannula, simple face
mask, and mask with reservoir bag).
 Pre triage screening area

Suspected Non- suspected

To designated
To the usual triage room
isolation area triage

Call PHEM and send to

quarantine
Follow subsequent ED flow

Figure A pre triage screening algorithm

ICU Management for 2019-nCov case
ICU Setup
1.1. Room
 Six beds
 Well ventilated (preferably negative pressured room)
 Area for a single bed should cover at least 20 m2
 Adequate power source & adequate plugs (6-8)
 Adequate water supply (which support dialysis) & sink
 Appropriate store room
 Staff counter should be separate
1.2. Drugs, equipment’s & Supplies-see annex 1,2 & 3
1.3. Human Resources
 Physicians: Intensivist, Anesthesiologist, pulmonary critical care or
emergency medicine specialist or trained physician
 Nursing: Short or long term EMCC trained nurses practicing in ICU led
by formally trained EMCC nurse. (1:1 or more)
  Porter(runner), Guard, janitor, Biomedical technician

Admission Criteria

1.4. General principle: unstable patients who will benefit most from the ICU and
patients with high risk of deterioration are prioritized for ICU admission.
1.5. Unstable and deteriorating patients -Requires intensive treatment and
monitoring that cannot be provided outside of theCritical care unit including:
 Mechanical ventilatory support (excluding mask continuous positive
airway pressure (CPAP) or non-invasive (eg, mask) ventilation)
 Possibility of a sudden, precipitous deterioration in respiratory function
requiring immediate endotracheal intubation and mechanical ventilation
 Need for vasoactive drugs to support arterial pressure or cardiac output
 Support for circulatory instability due to hypovolemia from any cause
which is unresponsive to modest volume replacement.
  Requires invasive monitoring and may potentially need immediate
intervention. E.g. a patient with chronic co-morbid conditions who
develops acute severe medical or surgical illness get priority.
1.6. Criteria based on V/s and other assessment for calling intensive care
admission
 Threatened airway
 All cardio respiratory arrests
 Respiratory rate ⩾40 or ⩽8 breaths/min
 Oxygen saturation <90% on ⩾50% oxygen, If there is ABG:Rising
arterial carbon dioxide tension with respiratory acidosis
 Pulse rate <40 or >140 beats/min
 Systolic blood pressure <90 mm Hg
 Sudden fall in level of consciousness (fall in Glasgow coma score >2
points)
 Repeated or prolonged seizures
 Other organ failures and metabolic, electrolyte and acid base
disturbances: Indications for considering renal replacement therapy and
significant electrolyte/ABG and biochemical disturbances
 Special judgment by clinicians

General management
Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia, or shock
1- Initiate oxygen therapy at 5 L/min

Titrate flow rates to reach target SpO2

-≥94% Children with emergency

- ≥90% in non-pregnant adults - ≥92-95 % in pregnant patients
signs during resuscitation

2-Use conservative fluid management in patients

with SARI when there is no evidence of shock
 3-Give emperic broad spectrum antimicrobials to treat all lik

Give antimicrobials within one hour of initial

patient assessment for patients with sepsis Emperic therapy should be de-escalated on the basis of

4-Closely monitor patients with SARI for signs of clinical

deterioration and apply supportive care interventions
immediately
5-Understand the patient’s co-morbid condition(s) to
tailor the management of critical illness

6-Communicate early with patient and family

Specific management
 Severe pneumonia
Adolescent/Adult Child with cough/difficulty
Fever or suspected in breathing +
Respiratory infection +one at least one of the
of: following: The diagnosis is clinical,
Respiratory rate>30/min chest radiograph may
Central cynosis/SpO2<90%
exclude complications
Severe respiratory distress Severe respiratory distress
SpO2<90% on room air Signs of severe pneumonia
with danger signs
 Acute Respiratory Distress
Syndrome
Onset mild
new/worsening respiratory symptoms ARDS:200<PaO2/FiO2<300mmHg(with Oxygenation
within one week PEEP/CPAP >5cmH2O, or non- (children:OI=Oxygenation Index and
ventilated OSI=Oxygenation Index Using SpO2)
Chest imaging
moderate ARDS: Bilevel NIV/CPAP>5cmH2O via full
bilateral opacities
100mmHg<PaO2/FiO2<200mmHg with facemask:PaO2/FiO2<300mmHg or
origin of edema PEEP>5cmH2O, or non-ventilated SpO2/FiO2<264
respiratory failure not fully expalined Severe ARDS: PaO2/FiO2<100mmHg Mild/moderate/severe
by cardiac failure or fluid overload with PEEP>5cmH2O, or non-ventilated ARDS(ventilated invasively)
It can be mild/moderate/severe When PaO2 is not available,
SpO2/FiO2<315 suggests ARDS

Management of hypoxemic respiratory failure and ARDS

1-Oxygen via face mask with reservoir bag-flow rates 10-15l/min
2-HFNO/NIV should only be used in selected patients without comorbidities
and non-pregnant
3-Monitor closely for one hour and invasive ventilation if acutely deteriorate or
no improvement
4-MV setting-low tidal volume (4-8MI/KG), low inspiratory pressure, high
PEEP
5-If no improvement consider prone ventilation, respiratory paralysis or ECMO.
 Sepsis
Signs of organ dysfunction:
altered mental status
difficult or fast breathing
low O2 saaturation
reduced urine output
Children:
Adults fast heart rate
suspected or proven infection and >/=
life-threatening organ dysfunction with weak pulse 2SIRS criteria, of which one must be
suspected orproven infection
cold extremities abnormal temperature or WBC COUNT
low blood pressure
skin mottling or
laboratory evidence of coagulopathy,
thrombocytopenia,acidosis, high lactate or
hyperbilirubinemia
 Septic Shock
Children:
(based on any hypotension or 2-3 of the following)
altered mental status
tachycardia or bradicardia(HR 160bpm in infants, 150bpm in
children
Adult:
prolonged capilary refill(>2sec) or warm vasodilation with
persisting hypotension despite volume resuscitation, requiring bounding pulses
vasopressors to maintatin MAP>/=65mmHg and tachypnea
Serum lactate level >2mmol/L mottled skin.petechial/purpuric rash
increased lactate
oliguria
hyper/hypothermia
Management of Sepsis/septic shock

Recognize and treat within one hour:

1-Antimicrobial therapy
2-Fluid loading
Adults: 30ml/kg isotonic crystalloid in the first 3hours
Children: 20ml/kg as rapid bolus
40-60ml/kg in the first hour
Follow for improvement, JVP and signs of pulmonary edema
If no improvement, raised JVP or pulmonary edema reduce fluid
3-Vasopressors (norepinephrine, epinephrine, vasopressin, and dopamine are
safe for use
Annex 1 -ICU inventory
Items Item number per ICU (six beds)
Ventilators 8
Connections 60
Nebulizer 6
Test lungs 2
Humidifier (Adult) 6
Blood warmer 2
Catheter mount 500
IBP Module 100
IBP cables 50
Pulse oxymeter 3
ECG machine 2
Torch 10
Glucometer 10
Shaving set 1
Tongue depressor 1 box
Minor set 6
Stethoscope 6
Knee hammer 6
Tuning fork 6
Cricothyroid set 2
Stillets 6
Laryngoscope(ordinary) 6
Ambu bag’s (adult) 6
Cordless phone 1
Bath basins 1
Double stands 12
O2 trolly’s 6
Wheel chair 1
Fumigation pump 1
Room heater 3
Monitor 6
ETCO2 Module 6
Temp probes 6
Otoscope 3
Defibrillator 1
Feeding cup 6
Steel kidney trays 12
Plastic kidney trays 6
Hot water bag 6
mattress 6
Enema can 6
Bed pan 6
Urinal 6
Shoe racks 40
Office chair 6
Couch (staff resting bed) 2
Bed side trolley 6
IV stand steel 6
Suction unit 6
Fridges 1
Computers 2
Pillows 10
ABG GEM machine 1
Wall clock 1
Infusion Pump 12
US 1
Portable x-ray 1
Dialysis machine 2
UPS 8