Combating Covid-19: Doctors should maximum give tele-consultation for next 2 weeks

CLINIC Establishment Guidelines Being Updated regularly

Dr KK Aggarwal [President CMAAO]

Dr Rajan Sharma (National President IMA)

Dr R V Asokan (HSG IMA)

Dr V K Monga (Chairman HBI)

Doctors:

Give maximum paid tele consultations for next two weeks

Doctors above 65yrs , uncontrolled diabetics, immunocompromised. Six minutes walk distance < 200 meters, unvaccinated for flu and pneumonia ( secondary or co infections common) should stop seeing OPD for two weeks and provide tele consultation only

All doctors should wear surgical mask (N 95 if doing ANY PROCEDURE where aerosols are produced) 3 What precautions Doctor has to take returning home from clinic.

Doctor with cough and fever: self-quarantine, get COVID test done ( Italy WHO study 90% of doctors attending patients were asymptomatic when found positive).

Returning home: Remember the way we treat the guests (wash feet first, then hands, than face, change cloths (keep them in separate box for washing), decontaminate all surfaces you have touched including your car, wash hands again with soap and water.

Stay away from elderly people in your home if possible.

Clinic: have air purifiers with 10 air exchanges per hour speed.

Caution: Your young children should not be looking after your parents. Have important phone numbers read COVID ambulances, Local DSO, COVID hospitals SEND SMS To all patients that if they or any close contact has and fever they should call and not directly come to the establishment. Educate the staff about hand wash, respiratory and personal hygiene and cough etiquette. Hand wash: Any soap and water, 20 seconds, >60% alcohol sanitiser,

Respiratory hygiene: cough and sneeze on tissue paper or sleeves

Cough: Maintain a distance of 1-2 meters

Provide access to surgical masks, liquid soap & sanitizers to all staff.

N 95 if they do any procedure producing aerosol including high pressure oxygen

Build Immunity

Educate every one about good food, rest, walks

Let non essential staff work from home

Accounts, PRO, relationships

Use infrared thermometers at the reception desk

Take temperature of all who enters the establishment

Put social distancing measures into place

Call patients with appointments to avoid crowding at reception / waiting area. Make then wait in Car and call them when their appointment is due. Separate waiting area for suspected COVID-19 patients (six feet distance). If possible make all OPD patients wear masks.

Take undertaking

That they or their family member is not having cough and fever. Any international travel of any family member/visitor.

Train Staff

Infection control tutorials. Create a backup call schedule to cover for ill staff.

Examination

Keep a distance of three feet, examine chest from back, make patient not sit face to face but face to side

If possible, run special cough cold and fever OPD for one hour in a fix time

Remember cold and stuffy nose with is present only in 4% of COVID 19 patients. It is flu unless proved otherwise.

Postpone non emergent cases or see them on video call

Stock

Create a plan to handle surge in case of increased patient volume ( worst 0.1% of your area). Maintain supply of masks, disinfectant/sanitizer and other personal protective equipment.

Disinfect three times a day

Computers, keyboards, scanners, door handles, BP instrument, stethoscope, SPO2 monitor, room with 0.1% bleach solution three times a day.

Keep hand sanitizer at all strategic points like reception, procedure rooms, reporting rooms etc.

Home care

Patients with mild infection who can be adequately isolated in the outpatient setting. Management of such patients should focus on prevention of transmission to others and monitoring for clinical deterioration, which should prompt hospitalization.

Outpatients with COVID-19 should stay at home and try to separate themselves from other people and animals in the household. They should wear a facemask when in the same room (or vehicle) as other people and when presenting to health care settings. Disinfection of frequently touched surfaces is also important.

Test-based strategy: Discontinue home isolation when there is:

•Resolution of fever without the use of fever-reducing medications AND

•Improvement in respiratory symptoms (eg, cough, shortness of breath) AND

•Negative results of a US Food and Drug Administration (FDA) Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens)

Non-test-based strategy: discontinue home isolation when the following criteria are met:

•At least seven days have passed since symptoms first appeared AND

•At least three days (72 hours) have passed since recovery of symptoms (defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms [eg, cough, shortness of breath])

In some cases, patients may have had laboratory-confirmed COVID-19, but they did not have any symptoms when they were tested. In such patients, home isolation may be discontinued when at least seven days have passed since the date of their first positive COVID-19 test so long as there was no evidence of subsequent illness.

The use of non-test-based strategies that use time since illness onset and time since recovery as the criteria for discontinuing precautions is based upon findings that transmission is most likely to occur in the early stage of infection. However, data are limited, particularly in immunocompromised patients, and this strategy may not prevent all instances of secondary spread.

Tests

Lymphocyte count: day 1. 7 and 14. Persistent low lymphocyte count is a bad sign.

D dimer > 1 on first visit is a bad sign

SPO2 < 90 is emergency Exertional fall of SPO2 > 4% with cough is a sign of early respiratory decompensation

High risk patients: six minutes walk distance < 200 meters, uncontrolled BP, sugar and heart failure

Do not ignore fever with cough, fever and low lymphocyte counts

Prophylaxis for health care providers, high risk case

Flu and pneumonia vaccine to all high-risk cases

Off label use: High risk patients (elderly, comorbid, six-minutes’ walk distance < 200 meters) and healthcare providers handling the COVID like cases the role of chloroquine 2 tablets per week/ or 2 tablets of hydroxy chloroquine2oo mg per week

Treatment

Throat swab for covid 19, hemogram ( lymphocyte count), CRP< LDH, D dimer, early CT chest, six minutes walk distance Start any Tamiflu brand 1 BD for five days Off label use: Hydroxychloroquine (200 mg three times per day for 10 days) plus Azithromycin 500 mg once daily for ten days in all COVID suspected or confirmed cases Off label high risk cases (persistent leukopenia on day 7, high SOFA score or D Dimer > 1); add Lopinavir 400 mg/ritonavir 100 mg twice daily or Lopinavir 800 mg/ritonavir 200 mg once daily can be added. (DCGI approved)

Quarantine policy

Quarantine staff after exposure to patients with suspected coronavirus.

Get COVID throat swab done of all high-risk contacts at day 5

Serious cases

Patients with severe disease often need oxygenation support.

High-flow oxygen

Non-invasive positive pressure ventilation

They are aerosol-generating procedures that warrant specific isolation precautions.

Some patients may develop acute respiratory distress syndrome and warrant intubation with mechanical ventilation; extracorporeal membrane oxygenation may be indicated in patients with refractory hypoxia.

((The writer is President, CMAAO, HCFI and Past national President IMA))