How to set up isolation ward in Hospitals: Health Ministry Guidelines

New Delhi: Union Ministry of Health and Family Welfare has released guidelines for Setting up Isolation Facility/Ward. The document is important in the wake of recent Covid 19 outbreak.

WHO has declared the COVID-19 (SARS-CoV-2) outbreak as Public Health Emergency of international concern and has raised the risk assessment of China, Regional Level and Global Level to Very High and "all countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of the onward spread of SARS-CoV-2 infection. Among the factors affecting cluster containment, Isolation of cases and quarantine of contacts is the mainstay of outbreak containment.

In this light guidance document has been prepared to establish an isolation facility at the level of the district hospital, a secondary health care facility. Following are its salient features

A. Quarantine and isolation

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

Quarantine

Quarantine refers to the separation of individuals who are not yet ill but have been exposed to COVID-19 and therefore have the potential to become ill. There will be a voluntary home quarantine of contacts of suspect /confirmed cases. The guideline on home quarantine available on the website of the Ministry provides detail guidance on home quarantine.

Isolation refers to the separation of individuals who are ill and suspected or confirmed of COVID-19. All suspect cases detected in the containment/buffer zones (till a diagnosis is made), will be hospitalized and kept in isolation in a designated facility till such time they are tested negative. Persons testing positive for COVID-19 will remain to be hospitalized till such time 2 of their samples are tested negative as per MoHFW's discharge policy. About 15% of the patients are likely to develop pneumonia, 5 % of whom requires ventilator management.

Hence dedicated Intensive care beds need to be identified earmarked. Some among them may progress to multi-organ failure and hence critical care facility/ dialysis facility/ and Salvage therapy [Extra Corporeal Membrane Oxygenator (ECMO)] facility for managing the respiratory/renal complications/ multi-organ failure shall be required. If such facilities are not available in the containment zone, nearest tertiary care facility in Government / private sector needs to be identified, which becomes a part of the micro-plan. There are various modalities of isolating a patient. Ideally, patients can be isolated in individual isolation rooms or negative pressure rooms with 12 or more air changes per hour.

In resource-constrained settings, all positive COVID-19 cases can be cohorted in a ward with good ventilation. Similarly, all suspect cases should also be cohorted in a separate ward. However, under no circumstances, these cases should be mixed up. A minimum distance of 1 meter needs to be maintained between adjacent beds. All such patients need to wear a triple layer surgical mask at all times.

Nosocomial infection in fellow patients and attending healthcare personnel are well documented in the current COVID-19 outbreak as well. There shall be strict adherence to Infection prevention control practices in all health facilities. IPC committees would be formed (if not already in place) with the mandate to ensure that all healthcare personnel are well aware of IPC practices and suitable arrangements for requisite PPE and other logistic (hand sanitizer, soap, water etc.) are in place. The designated 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.

At all times doctors, nurses and para-medics working in the clinical areas will wear three layered surgical mask and gloves. The medical personnel working in isolation and critical care facilities will wear full complement of PPE (including N95 masks).

The support staff engaged in cleaning and disinfection will also wear full complement of PPE. Environmental cleaning should be done twice daily and consist of damp dusting and floor mopping with Lysol or other phenolic disinfectants and cleaning of surfaces with sodium hypochlorite solution. Detailed guidelines available on MoHFW's website may be followed.

B. Setting up isolation facility/ward

An isolation facility aims to control the airflow in the room so that the number of airborne infectious particles is reduced to a level that ensures cross-infection of other people within a healthcare facility is highly unlikely.

• At State level, a minimum of 50 bed isolation ward should be established.
• At District level, a minimum of 10 bed isolation ward should be established.
• Post signages on the door indicating that the space is an isolation area.
• Remove all non-essential furniture and ensure that the remaining furniture is easy to clean, and does not conceal or retain dirt or moisture within or around it.
• COVID-19 patients should be housed in single rooms.
• However, if sufficient single rooms are not available, beds could be put with a spatial separation of at least 1 meter (3 feet) from one another.
• To create a 10 bed facility, a minimum space of 2000 sq. feet area clearly segregated from other patientcare areas is required.
• Preferably the isolation ward should have a separate entry/exit and should not be co-located with post-surgical wards/dialysis unit/SNCU/labour room etc.
• It should be in a segregated area which is not frequented by outsiders.
• The access to isolation ward should be through dedicated lift/guarded stairs.
• There should be double door entry with changing room and nursing station. Enough PPE should be available in the changing room with waste disposal bins to collect used PPEs.Used PPEs should be disposedas per the BMWM guidelines.
• 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. A checklist may be useful to ensure that all equipment is available.
• Place appropriate waste bags in a bin. If possible, use a touch-free bin. Ensure that used (i.e. dirty) bins remain inside the isolation rooms.
• Place a puncture-proof container for sharps disposal inside the isolation room/area and bio-medical waste should be managed as per the BMWM guidelines.
• Keep the patient's personal belongings to a minimum. Keep water pitchers and cups, tissue wipes, and all items necessary for attending to personal hygiene within the patient's reach.
• Non-critical patient-care equipment (e.g. stethoscope, thermometer, blood pressure cuff, and sphygmomanometer) should be dedicated for the patient, if possible. Any patient-care equipment that is required for use by other patients should be thoroughly cleaned and disinfected before use.
• Place an appropriate container with a lid outside the door for equipment that requires disinfection or sterilization.
• 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.
• Ensure adequate room ventilation. If room is air-conditioned, ensure 12 air changes/ hour and filtering of exhaust air. A negative pressure in isolation rooms is desirable for patients requiring aerosolization procedures (intubation, suction nebulisation). These rooms may have standalone air-conditioning. These areas should not be a part of the central air-conditioning.
• 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.
• In district hospital, where there is sufficient space, 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. The principle of natural ventilation is to allow and enhance the flow of outdoor air by natural forces such as wind and thermal buoyancy forces from one opening to another to achieve the desirable air change per hour.
• The isolation ward should have a separate toilet with proper cleaning and supplies.
• Avoid sharing of equipment, but if unavoidable, ensure that reusable equipment is appropriately disinfected between patients.
• Ensure regular cleaning and proper disinfection of common areas, and adequate hand hygiene by patients, visitors and care givers.Keep adequate equipment required for cleaning or disinfection inside the isolation room or area, and ensure scrupulous daily cleaning of the isolation room or area.
• Visitors to the isolation facility should be restricted /disallowed. For unavoidable entries, 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.
• Ensure that visitors consult the health-care worker in charge (who is also responsible for keeping a visitor record) before being allowed into the isolation areas. Keep a roster of all staff working in the isolation areas, for possible outbreak investigation and contact tracing.
• Doctors, nurses and paramedics posted to isolation facility need to be dedicated and not allowed to work in other patient-care areas.
• Consider having designated portable X-ray and portable ultrasound equipment.
• Corridors with frequent patient transport should be well-ventilated.
• All health staff involved in patient care should be well trained in the use of PPE.
• Set up a telephone or other method of communication in the isolation room or area to enable patients, family members or visitors to communicate with health-care workers. This may reduce the number of times the workers need to don PPE to enter the room or area.

C. Checklist for isolation rooms

• Eye protection (visor or goggles)    
• Face shield (provides eye, nose and mouth protection)
• Gloves
• reusable vinyl or rubber gloves for environmental cleaning
• latex single-use gloves for clinical care
• Hair covers
• Particulate respirators (N95, FFP2, or equivalent)
• Medical (surgical or procedure) masks
• Gowns and aprons
• single-use long-sleeved fluid-resistant or reusable non-fluid-resistant gowns
• plastic aprons (for use over non-fluid-resistant gowns if splashing is anticipated and if fluid-resistant gowns are not available)
• Alcohol-based hand rub
• Plain soap (liquid if possible, for washing hands in clean water)
• Clean single-use towels (e.g. paper towels)
• Sharps containers
• Appropriate detergent for environmental cleaning and disinfectant for disinfection of surfaces, instruments or equipment
• Large plastic bags
• Appropriate clinical waste bags
• Linen bags
• Collection container for used equipment
• Standard IEC
• Standard protocols for hand hygiene, sample collection and BMW displayed clearly
• Standard Clinical management protocols

D. 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;
• Put on PPE in the order that ensures adequate placement of PPE items and prevent self-contamination and self-inoculation while using and taking off PPE; an example of the order in which to don PPE when all PPE items are needed is hand hygiene, gown, mask or respirator, eye protection and gloves

Leaving the isolation room or area

• Either remove PPE in the anteroom or, if there is no anteroom, make sure that the PPE will not contaminate either the environment outside the isolation room or area, or other people.
• Remove PPE in a manner that prevents self-contamination or self-inoculation with contaminated PPE or hands. General principles are:

– remove the most contaminated PPE items first;

– perform hand hygiene immediately after removing gloves;

– remove the mask or particulate respirator last (by grasping the ties and discarding in a rubbish bin);

– discard disposable items in a closed rubbish bin;

– put reusable items in a dry (e.g. without any disinfectant solution) closed container; an example of the order in which to take off PPE when all PPE items are needed is gloves (if the gown is disposable, gloves can be peeled off together with gown upon removal), hand hygiene, gown, eye protection, mask or respirator, and hand hygiene

– Perform hand hygiene with an alcohol-based hand rub (preferably) or soap and water whenever un-gloved hands touch contaminated PPE items.

E. Transport of Infectious Patients

It is recommended that transport of infectious patients is limited to movement considered medically essential by the clinicians, e.g. for diagnostic or treatment purposes. Where infectious patients are required to be transported to other units within the hospital or outside the following precautions may be implemented:

• Infected or colonised areas of the patient's body are covered: - For contact isolation this may include a gown, sheets or dressings to surface wounds; these patients are transferred to a Standard Pressure or Protective Environment Isolation room - For respiratory isolation the patient is dressed in a mask, gown and covered in sheets; these patients are accommodated in a Negative Pressure Isolation Room - For quarantine isolation the patient may be transported in a fully enclosed transport cell or isolator with a filtered air supply and exhaust; these patients are accommodated in a high level quarantine isolation suite.
• The transport personnel remove existing PPE, cleanse hands and transport the patient on a wheelchair, bed or trolley, applying clean PPE to transport the patients and when handling the patient at the destination. Gown-up and gown-down rooms located at the entry to a Unit will assist the staff to enter and exit the facility according to the strict infection control protocols required, thereby reducing the risk of contamination
• The destination unit should be contacted and notified prior to the transfer to ensure suitable accommodation on arrival.
• It is preferred that the patient is transported through staff and service corridors, not public access corridors During planning stages, design can assist transfer of infectious patients by providing service corridors and strategically placed lifts, capable of separation from other lifts. The nominated lift may be isolated from public and staff transit through access control measures and cleaned following transit of the infectious patient.
• Design may also incorporate a designated floor for horizontal bed transfers of infectious patients away from busy clinical areas. The designated floor may be located at mid-level in the hospital
• 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.

Annexure I

Checklist for isolation rooms

• Eye protection (visor or goggles)
• Face shield (provides eye, nose and mouth protection)
• Gloves
• reusable vinyl or rubber gloves for environmental cleaning
• latex single-use gloves for clinical care
• Hair covers
• Particulate respirators (N95, FFP2, or equivalent)
• Medical (surgical or procedure) masks
• Gowns and aprons
• single-use long-sleeved fluid-resistant or reusable non-fluid-resistant gowns
• plastic aprons (for use over non-fluid-resistant gowns if splashing is anticipated and if fluid-resistant gowns are not available)
• Alcohol-based hand rub
• Plain soap (liquid if possible, for washing hands in clean water)
• Clean single-use towels (e.g. paper towels)
• Sharps containers
• Appropriate detergent for environmental cleaning and disinfectant for disinfection of surfaces, instruments or equipment
• Large plastic bags
• Appropriate clinical waste bags
• Linen bags
• Collection container for used equipment
• Standard IEC
• Standard protocols for hand hygiene, sample collection and BMW displayed clearly
• Standard Clinical management protocols

Annexure II 

For further details, on proforma and annexures regarding this guideline, click on the following link

https://www.rguhs.ac.in/scroll2020/Corona20032020.pdf