The coronavirus (COVID-19) pandemic continues to spread like wildfire across the world claiming over 100,000 lives and overtly infecting over 2.0 million people.  Its advance has caught most of the developed countries off guard, despite all their resources. Thus, it is vital that hospitals in developing countries who are yet ahead of the curve, adapt and implement the established best practice principles immediately to reduce risk to their staff and patients.
SARS-CoV-2, the causative virus, is highly efficient in person-to-person transmission, and for a relatively low infective dose. It spreads by respiratory droplets, aerosols and contact.  The virus loaded droplets and aerosols can settle on fomites, where it is able to survive on certain surfaces for up to 72 hours. The infected can remain silent carriers for up to 14 days, as the symptoms develop slowly, with approximately a third of patients not developing any symptoms. [2,3] These asymptomatic and pre-symptomatic patients are still able to shed virus which resides in their lungs. Research is suggesting that the virus’ infectivity peak is before the development of symptoms, and the virus may be shedding up to 37 days in severe cases. [4,5,6]
The majority who develop symptoms manifest breathing difficulties, muscle pains, cough and fever; however, 15% of these cases develop severe pneumonia requiring intensive care.  The infected who display mild illness may evolve over a course of a week to recovery or severe respiratory distress depending on their individual factors. Whilst it is reported that the virus has a propensity to affect the elderly, the comorbid and the immune-compromised more severely, this is not exclusive as previously healthy and young individuals have also ended up on ventilators and died.
Evidence suggests that the accrued viral load also plays a role in manifesting severe disease.  This is particularly worrying for healthcare workers who repetitively see ill people and get exposed to a high dose of viral load over time and succumb to illness. Several frontline staff across the world have fallen ill and died in the line of duty. Italy’s outbreak figures reveal that 10% of all infections were in healthcare workers. 
It is obvious that the detrimental effects of this pandemic cannot be underestimated and represent a national emergency. Pakistan is likely two or three weeks behind its expected peak of COVID-19 cases and associated mortality. There is still limited time to implement safety measures across its hospitals to protect patients and healthcare workers. It is imperative that the healthcare model is changed to enhance safety, including modifications to the clinical and theatre workplace, implementing infection control precautions and sourcing appropriate personal protective equipment.
Clinical Workplace Modifications
- Routine clinical work should cease with immediate effect to reduce any excess and avoidable exposure to staff and patients, especially the elderly who are at an increased risk of becoming infected leading to severe illness with a high mortality rate.
- Hospitals and clinics should only prioritize to see those patients who can come to irreversible harm to life, limb or organ, if not treated immediately.
- Face-to-face time during clinic consultations needs to be minimized. Virtual clinics and telephone triage can be done in clinics with the patient’s medical records available. Patients can be called on their mobile phones for consultations instead of attending routine clinics. These virtual consultations can be also used to flag patients that necessitate further checks and a physical examination or urgent procedures in person. These patients should also be scrutinized to see if they have any COVID-19 symptoms to help guide their management.
- The identified patients needing an in-person further examination can be booked in a special clinic with specific time slots at well-staggered time intervals. This will allow patients to reduce face-to-face time with other patients and maintain virus shedding at the healthcare workplace to a minimum.
- Patients should be encouraged to arrive at a specific time and wait in their car or in an open area outside the hospital until called in for their appointment. In-hospital patient waiting areas for the selected patients should be in an open room with good ventilation and windows open. Seating arrangements must be staggered with a gap of 2 meters between seats.
- Patients should attend by themselves or with one carer at maximum.
- Upon entry, the patients and carers must be wearing face masks, provided by the hospital as necessary. Immediately prior to entry, they should also be screened again for COVID-19 symptoms and have their temperature checked to allow appropriate arrangements for symptomatic vs asymptomatic patients.
- Any examination must be focused and the pathways should include being seen by the least number of healthcare professionals possible. This may mean ordering a limited number of focused investigations to assist diagnosis and treatment.
- There should be minimal talking during the examination, history taking having been completed by phone prior to physical attendance. All explanations and counselling after examination should be done remotely to reduce face-to-face time and discussion in clinics.
- There should be a designated separate entrance and exit for attending patients.
- Staff who are old, co-morbid or ill should be removed from face to face clinical interactions.
- Staff working in healthcare should be tested and re-tested for COVID-19 at regular intervals as a priority.
Operating Theatre Modifications
- Only operate on absolute emergencies where there is a risk of loss of life or limb or organ.
- Theatre environment should contain the minimum amount of equipment and only the necessary trolleys with prepared instruments should be wheeled in for use.
- General anesthetic cases should be avoided as far as possible, as intubation is an aerosol generating procedures. Local anesthetic alternatives should be considered where possible.
- Surgical methods involving high speed drills should be avoided as much as possible, as it generates aerosols. Careful consideration should also be given to ear, nose and throat surgical procedures as well as they are capable of micro-aerosol production.
- Full personal protective equipment must be utilized for all surgical procedures including respirators, eye protection, gloves and gowns to protect staff.
Infection Control Guidance
- There should be strict bare below the elbow policy followed throughout the workplace.
- Regular hand washing for 20 seconds should be followed by all staff. Patients should also wash hands on entry to the unit and before leaving. Upon arrival at home, they should again wash hands.
- All personnel in the department should instructed to never touch their face. This is to ensure that there is protection of all mucous membranes; eyes, nose and mouth. These are portal of entries of the virus to the body.
- There should be strict non-touch of all surfaces unless unavoidable.
- There should be no handshakes or hugs between staff and patients.
- Staff should not accrue in rooms and maintain a distance of 2m at all times.
- There should not be any face to face meetings, and where possible telephone and e-meetings should be organized instead.
- Clinical interactive surfaces should be cleaned with alcohol-based or bleach-based disinfectants.
- Staff should designate workplace uniform and shoes which should be changed at the workplace, and regularly washed at or above 60 degrees.
Personal Protective Equipment (PPE)
- Masks are important for respiratory protection as they cover mucous membranes of nose and mouth.
Surgical masks should be properly molded to the user’s nasal bridge and are suitable for use if performing non-aerosol generating procedures and examinations on asymptomatic patients. They should also be worn by all healthcare staff even when not interacting with patients to reduce risk of transmission to each other.
Respirators should be used for all symptomatic patients. Respirators need to be fit tested using qualitative or quantitative methods to ensure they are correctly fitting to the user’s face. Men who have beards cannot use respirators and will require positive pressure hoods. Consideration should be given to a no facial hair policy during the pandemic.
- Eye protection is also vital as it shields mucous membranes of the eyes. There should be appropriate use of visors or goggles for close examination of all cases and routine examination of all high-risk cases. If goggles are used, it should be ensured that they snuggly fit around the eye socket.
- Gowns or Aprons should be appropriately used in all high-risk areas to protect dispersal on skin and clothes.
- Proper training for donning and doffing PPE in clinics and theatre environment is essential for all staff. This will ensure reducing risk of self-inoculation and infecting others in the removal and disposal of virus laden protective gear.
Ethical and Personal Challenges for Healthcare
These difficult and testing times will force doctors to take decisions on who to admit, who to ventilate and who to treat when there is insufficient capacity and protective equipment. Institutions should discuss these scenarios in preparation.
- It has to be carefully considered to not ventilate those who have a low chance of survival if there is insufficient capacity.
- In the situation of inadequate PPE availability, the healthcare workforce should not be pressurised to provide treatment to COVID-19 patients including resuscitation.
- Healthcare staff may have to separate their lives from their families to protect them, and some may have to live apart if they have family members at high risk of dying from COVID-19.
- Doctors should be provided access to mental health support in these difficult times.
(The article was published by Jinnah Institute)
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