A CAPSULE COURSE FOR BATTLE FIELD

NURSING ASSISTANTS ON COVID-19

A COMPREHENSIVE TRAINING MODULE

Directorate General of Medical Services (Army)

O/o Addl DGMNS, DGMS-4
‘L’ Block, New Delhi - 110001
 PREFACE

Armed Forces Medical Services is structured to provide preventive, promotive, curative and
rehabilitative care to defence personnel and their families. Battle Field Nursing Assistants (BFNA)
are the grass root level workers who can percolate down to latitudes and longitudes of the troops.

With a paradigm shift in today’s health care scenario, it is essential to train all health care
workers regarding the knowledge and skills to prevent the spread of infection. Battle Field Nursing
Assistants play a central role in imparting basic knowledge and improving the access to health care
as far as the troops are concerned.

In view of the above, a felt need was rightly identified by the Director General Medical Services
(Army) and conceptualised this capsule course for the Battle Field Nursing Assistants. This
endeavour gives a comprehensive yet simple illustration of basic knowledge regarding the COVID-19
dynamics, self-protection, triage, disaster management, community prevention and stress
management. This module is drafted to cater the physical, mental, social and spiritual domains of
health and well-being.

I am sanguine that this venture will equip them with the necessary knowledge and skill to
prevent and contain the pandemic within the territories and effectively aid in breaking the chain of
transmission. This humble submission may be a small drop in the ocean of “Operation Namaste”
launched by the Chief of Army Staff on 27 Mar 2020.

Jai Hind!

Place : New Delhi (Joyce Gladys Roach)

Maj Gen
Date : 31 Mar 2020 Addl DGMNS

2
 INDEX

Contents Page No
Introduction, Aim and Course Description 04
Course Outline 05 - 06
UNIT - I : COVID-19 - Disease, Symptoms, Care and Mock Drills 07 - 13
1. Introduction to COVID-19 07
2. Differential Diagnosis & Myths vs Facts and testing strategies 08
3. Laboratory Investigations 09
4. Mock Drills for emergency response for handling COVID-19 10
UNIT - II : Patient Handling and Disaster Preparedness 14 - 21
5. PPE - use and self-protection during handling casualties 14
6. Safe Patient handling techniques 14
7. Triage, Hospital Admission and Home-care 18
8. Disaster Management 20
UNIT - III : Cleaning, Disinfection and Waste Management 22 - 25
9. Bio-medical Waste (BMW) Management 22
10. Infection prevention and control 23
11. General Guidelines during casualty management 24
12. Methods of cleaning and disinfection of articles 24
UNIT - IV : Community Prevention, Stress Management & Government Initiatives 26 - 30
13. Instructions / Health Education for caretakers 26
14. COVID-19 and Mental Toll 27
15. India’s Fight with COVID-19 with special emphasis to AFMS 28
UNIT - V : Standard Precaution : Dead Body Management 31 - 33
16. Dead Body Management 31
UNIT - VI : Evaluation & De-briefing 34
17. OSPE (Assessment) 34
18. Distribution of training certificate

3
 A CAPSULE COURSE FOR BATTLE FIELD NURSING ASSISTANTS ON COVID-19

Introduction.

Corona Virus Disease 2019 (COVID-19) is a pandemic infectious disease spread from one
person to the other. With the ongoing disaster events due to the virus, there has been great impact on
the life of an individual, family and social system. Hence the knowledge and skills in handling this
disease is very essential for Health Care Workers.

Aim.

This capsule course is designed for Battle Field Nursing Assistants (BFNAs) to prepare them
with knowledge, skills and attitude in providing First Aid to the casualties without the fear of the
pandemic disease i.e. COVID-19.

Course Description.

This Capsule Course is designed to develop an understanding of the ongoing pandemic

COVID-19 disease and to practice effective self-care techniques as well as the care of the casualties
for Battle Field Nursing Assistants.

Duration : 06 days
Time : Theory - 11.15 hours
Practical - 3.45 hours

4
 COURSE OUTLINE
S. Learning Content Time (hrs) Teaching Assessment
No. Objectives Learning Evaluation
Activities Methods
DAY - 1
UNIT 1 : INTRODUCTION, AIM AND COURSE DESCRIPTION
1. Knowledge of what 1. Introduction to COVID-19 Pre-Test 04 lectures Lecture Question
is COVID-19 1.1. What is COVID-19 (theory) 45 cum Answer
1.2. Global Scenario mins each Discussion
1.3. Common Symptoms
1.4. Mode of Spread
1.5. High Risk Category
2. Differentiating 2. Differential Diagnosis, Myths Vs Facts & Testing Lecture Discussion
COVID-19 and Strategy cum
knowledge of 2.1 Cold Vs Flu Vs COVID-19 Discussion
testing strategy 2.2 Myths & Facts
2.3 COVID -19 testing strategy
4. Knowledge of 3. Laboratory Investigations Lecture Assignment
Laboratory 3.1 General Guidelines Sample Collection cum
Investigation 3.2 Material required Discussion
3.3 Patient preparation
3.4 Type of Sample
3.5 Sample Transportation
3.6 Investigation
DAY - 2
UNIT 2 : PATIENT HANDLING AND DISASTER MANAGEMENT
5. Provide efficient 4. Mock Drills for Emergency Response for handling 04 lectures Lecture Checklist
emergency COVID-19 (Theory) 45 cum filling
response while 4.1 OPD Devices/Initial Triage minutes discussion
handling patients 4.2 Emergency / In-Patient facilities/Isolation Rooms each
4.3 Duty Station
4.4 ICU Facility
4.5 Ambulance/Transfer vehicle for shifting
4.6 Check list for transport & arrival of patients
6. Practice standard 5. PPE, Use & Self Protection while handling casualties Lecture Discussion
precautions of PPE 5.1 Different PPE cum
while casualty 5.2 Principles to use PPE discussion
handling 5.3 Areas where PPE is used
5.4 Face Mask and their disposal
5.5 Safe Techniques and appropriate use of PPE
5.6 Removing PPE
7. Practice effectively 6. Safe patient handling techniques Video Discussion
self protection 6.1 Hand Hygiene assisted
techniques while 6.2 Hand Washing Techniques teaching
handling COVID-19/ 6.3 Respiratory Hygiene and Etiquettes demos
suspected cases 6.4 Wearing of PPE reinforced
on Day 4 &
5
8. Aware of Triage 7. Triage and Hospital Admission Lecture Discussion
and Hospital 7.1 Triage cum
Admission 7.2 Transportation Discussion
7.3 Hospital Admission
7.4 Isolation and Quarantine
7.5 Home-care for suspected cases
9. Describe the 8. Disaster Management Lecture Discussion
Disaster 8.1 Administrative Control cum
Management 8.2 Disaster Management Act 2005 Discussion
policies r/t COVID- 8.3 Offenses and Penalties
19 8.4 Cancellation of Non-Essential Services
8.5 Community Management Services

5
S. Learning Content Time (hrs) Teaching Assessment
No. Objectives Learning Evaluation
Activities Methods
DAY - 3
UNIT 3 : CLEANING, DISINFECTION AND WASTE MANAGEMENT
10. Apply principles as 9. Bio-Medical Waste Management 03 lectures Lecture Question
per protocol of 9.1 Segregation of Bio-Medical Waste (Theory) 45 cum Answer
BMW Management 9.2 Colour Code mins each discussion
9.3 Labelling of Bio-Medical Waste + 01 Demo
9.4 Packing and Transportation 45 mins
9.5 Disposal of BMW
9.6 General guidelines to handle BMW
11. Prevent 10. Prevention of Environmental Contamination Lecture Discussion
environmental cum
contamination while discussion
handling casualties 10.1 Environment cleaning and disinfection
10.2 Infection Prevention and Control (IPC)
10.3 Standard Precautions
10.4 Breaking the chain of transmission
12. Adhere to general 11. General Guidelines during Casualty Management Lecture Discussion
guidelines by cum
authorities discussion
13. Implement cleaning 12. Methods of Cleaning and Disinfection of Articles Lecture Discussion
and Disinfection 12.1 Methods of cleaning & disinfection all articles cum and Demo
techniques discussion
and Demo
DAY - 4
UNIT 4 : COMMUNITY PREVENTION, STRESS MANAGEMENT AND GOVT INITIATIVES
14. Ensure adherence 13. Instructions/Health Education for Caretakers 3 lectures Lecture Question
to instructions to 13.1 Role of Nutrition (Theory) 45 cum Answer
HCW 13.2 Common food myths COVID-19 mins each discussion
13.3 Self Protection + 01 Demo
13.4 Recommended items to carry 45 mins
15. Practice mental 14. COVID-19 and Mental Toll Lecture Asking group
hygiene techniques 14.1 Stress during outbreak cum about their
to prevent stress 14.2 Tips to remain optimistic & mgt of stress discussion reactions
along with 14.3 DO’s and DON’T’s
counselling others 14.4 Counselling and Psychosocial Support
16. Aware about the 15. India’s Fight with COVID-19 - special emphasis to Lecture Discussion
COVID fight AFMS cum
measures avl in 15.1 Evaluation measures discussion
AFMS 15.2 Approach of AFMS for COVID-19
15.3 Role of BFNAs
DAY - 5
UNIT 5 : STANDARD PRECAUTIONS : DEAD BODY MANAGEMENT
17. Dead body 16. Dead Body Management 01 lecture Lecture Evaluation
management 16.1 Standard Precautions : General (Theory) 45 cum
16.2 Removal of the body from isolation room mins + 03 discussion
16.3 Handling of dead body in mortuary demo
16.4 Embalming
16.5 Body Bags specification
DAY - 6
EVALUATION AND DE-BRIEFING
18. Evaluating the 17. Post Test and Return Demonstration Test Evaluation
learning outcomes Return
Demo

6
 UNIT - I

COVID-19 - DISEASE, SYMPTOMS, CARE AND MOCK DRILLS

1. Introduction to COVID-19.

1.1 What is COVID-19. COVID-19 is a disease caused by the novel corona virus. The name
of this new disease was announced by WHO (World Health Organisation) on 11 th Feb 2020
(previously known as “2019 novel corona virus”). The name of the virus is severe acute
respiratory syndrome corona virus 2 (SARS-CoV-2).

The virus was first detected in Wuhan, China in a live animal market. About 80% of
confirmed cases recover from the disease without any serious complications. However, one out
of every six people who gets COVID-19 can become seriously ill and develop difficulty in
breathing. In more severe cases, infection can cause severe pneumonia and other
complications which can be treated only at higher level facilities (District Hospitals and above).
In a few cases it may even cause death.

1.2 Global Scenario. On 11 March 2020, WHO declared Novel Coronavirus Disease
(COVID-19) outbreak as a pandemic and requested all countries to take immediate actions and
scale up response to treat, detect and reduce transmission to save people’s lives. The number
of COVID-19 cases, globally as on 29/03/2020 (Source: https://www.who.int/) are:-

(aa) 6,64,103 confirmed cases [16,22,167 as on 10 Apr]

(ab) 30,880 confirmed deaths [98,401 as on 10 Apr]

(ac) 1,42,361 total recovered [3,65,250 as on 10 Apr]

(ad) 202 countries affected [210 countries affected as on 10 Apr]

In India, as of 29 March, according to the Ministry of Health & Family Welfare

(MoHFW), around 1000 COVID-19 cases have been reported in 27 states/union territories and
21 reported deaths. Hospital isolation of all confirmed cases, tracing and home quarantine of
the contacts is going on. On 24 March 2020, the Prime Minister announced a 21-day nationwide
lockdown. In order to protect the country, and each of its citizens, a complete ban is being
imposed on people from stepping out of their homes.

1.3 Mode of spread. COVID-19 spreads mainly by droplets produced as a result of coughing
or sneezing of a COVID-19 infected person. The incubation period of COVID-19 (time between
getting the infection and showing symptoms) is 1 to 14 days. Some people with the infection,
but without any serious symptoms can also spread the disease. The spread can happen in two
ways:-

(aa) Direct Close Contact: one can get the infection by being in close contact with
COVID-19 patients (within one metre of the infected person), especially if they do not
cover their face when coughing or sneezing.

(ab) Indirect Contact: the droplets survive on surfaces and clothes for many days.
Therefore, touching any such infected surface or cloth and then touching one’s mouth,
nose or eyes can transmit the disease.

1.4 Common symptoms.

(aa) Fever.

(ab) Dry cough.

(ac) Breathing difficulty.

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 (ad) Some patients also have nasal congestion, running nose, sore throat, aches and
pains or diarrhoea.

1.5 High risk category.

(aa) People who have travelled to other countries after the outbreak.

(ab) People travelling across borders within and outside the country.

(ac) Family members & contacts of patients confirmed to have COVID-19.

(ad) Older adults (60 years of age).

(ae) People who have serious medical conditions like high blood pressure, heart
problems, respiratory disease/asthma, cancer or diabetes.

2. Differential Diagnosis and Myth Vs Facts.

2.1 Cold vs Flu vs COVID-19.

SYMPTOM CHART: WHAT TO WATCH FOR

Symptoms Coronavirus Cold Flu
Symptoms range from Gradual onset of Abrupt onset of
mild to severe symptoms symptoms
Fever Common Rare Common
Fatigue Sometimes Sometimes Common
Cough Common* (usually dry) Mild Common* (usually dry)
Sneezing No Common No
Aches and Pains Sometimes Common Common
Runny or stuffy Rare Common Sometimes
nose
Sore throat Sometimes Common Sometimes
Diarrhoea Rare No Sometimes for children
Headaches Sometimes Rare Common
Shortness of breath Sometimes No No

2.2 Myths vs reality for COVID-19 . As COVID-19 is a new condition, there are many
common myths.

Myths Facts
The corona virus can be The corona virus CANNOT be transmitted through
transmitted through mosquito bites.
mosquitoes.
Everyone should wear a mask. People who should wear a mask are:
 Those having symptom of fever, cough etc.
 Healthcare workers in facilities caring for ill people.
 The assigned care taker of a home quarantined
person.
 Even those wearing masks should wash their hands
frequently.
Only people with symptoms of Even people with the COVID-19 infection but no
COVID-19 can spread the symptoms can spread the disease
disease.

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 2.3 COVID-19 Testing Strategy.

Objectives:-

(aa) To contain the spread of infection of COVID-19.

(ab) To provide reliable diagnosis to all individuals meeting the inclusion criteria of
COVID-19 testing.

Current Testing Strategy:-

(ac) All symptomatic individuals who have undertaken international travel in the last 14
days.

(ad) All symptomatic contacts of laboratory confirmed cases.

(ae) All symptomatic health care workers.

(af) All hospitalised patients with Severe Respiratory Illness (Fever and Cough/or
Shortness of Breath).

(ag) Asymptomatic direct and high-risk contacts of a confirmed case should be tested
once between day 5 and day 14 of coming in his/her contact.

3. Laboratory Investigations.

3.1 General guidelines for Sample Collection.

(aa) As far as possible the sample should be collected at the place of examination/Ml
Room/Flu clinic. Unnecessary movement of suspected case should be avoided in hospital
premises to avoid exposure to others.

(ab) Appropriate clinical sample need to be collected by Resident doctor/ Nursing Officer/
Nursing Asst/ laboratory personnel/ or any health care worker trained in specimen
collection in presence of a clinician.

(ac) Clinical samples should be collected following all bio-safety precautions and using
PPEs.

(ad) OIC lab will ensure that all clinical samples are sent to the designated centres
recognised by ICMR following standard triple packaging.

3.2 Materials required for Sample Collection.

(aa) Vials containing Virus transport medium (VTM): Qty 01

(ab) Nylon or Dacron flocked swab: Qty 02.

(ac) Adsorbent material (Cotton, tissue paper, Para film, Seizer, Cello tape).

(ad) A leak-proof secondary container (e.g. Ziplock pouch, Cryobox, 50 ml centrifuge

tube, plastic container).

(ae) Hard frozen Gel packs.

(af) A suitable outer container (e.g. Thermocol box, ice box, hard-board box) (Minimum
dimension: 10x10x10 cm).

(ag) Personal Protective Equipment: Gloves, surgical mask and gown and eye shield.

(ah) Ball point pen and Permanent marker.

9
 (ai) Facility for hand hygiene (Soap and water or Alcoholic hand rub).

(aj) Yellow bag for disposal of bio-medical wastes.

(ak) Labels for outer box during transportation.

3.3 Patient Preparation.

It is a responsibility of Clinician to prepare the patient i.e. to ensure that the patient is
aware of collection procedure. He should inform the patient about the entire procedure.

3.4 Type of Sample.

Essential samples include Throat swab (oropharyngeal swab) and Nasal swab
(Nasopharyngeal swab). Other preferred samples are Bronchoalveolar lavage. Endo-tracheal
aspirate in wide mouth sterile plastic containers, Blood for bacteriological culture and Stool and
urine Human Serum, plasma or whole blood for virus isolation in confirmed patients.

The sample should be collected within 3 days of symptom onset and no later than 7 days -
Preferably prior to initiation of antiviral chemoprophylaxis.

3.5 Sample Transportation.

All samples will be transported to the respective testing centres in the state recognised by
ICMR. Handle the samples carefully using Gloves.

3.6 Investigation. Real time PCR (Polymerase Chain Reaction).

4. Mock drills for Emergency Responses for handling COVID-19.

Use clinical triage in health care facilities for early identification of patients with acute respiratory
infection (ARI) to prevent the transmission of pathogens to health care workers and other patients.

4.1 OPD Services / Initial Triage.

The basic principles of Infection Prevention and Control and standard precautions should be
applied in all health care facilities, including outpatient care and primary care. These are:-

(aa) Triage and early recognition.

(ab) Emphasis on hand hygiene, respiratory hygiene has to be made. Medical masks
must be used by patients with respiratory symptoms.

(ac) If possible, place patients in separate rooms or away from other patients in the
waiting rooms and wear mask, gloves and gown if possible when seeing them in the clinic.

(ad) When symptomatic patients are required to wait, ensure they have a separate
waiting area (1 m separation).

(ae) Educate patients and families about the early recognition of symptoms, basic
precautions to be used and which health care facility they should refer to.

(af) Prevent overcrowding.

(ag) Place ARI patients in dedicated waiting areas with adequate ventilation.

(ah) Ask patients with respiratory symptoms to perform hand hygiene, wear a mask and
perform respiratory hygiene.

(ai) Ensure at least 1 m distance between patients.

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4.2 Emergency / In-Patient Facilities / Isolation Rooms.

(aa) Place patients with ARI of potential concern in single, well ventilated room, when
possible.

(ab) Keep patients with the same diagnosis in one area.

(ac) Do not place suspect patients in same area as those who are confirmed.

(ad) Follow contact and droplet precautions for all patients with suspected or confirmed
COVID-19.

(ae) Keep patients preferably in a single room.

(af) Wear PPE’s whenever required.

(ag) Perform hand hygiene frequently.

(ah) Equipment should be single use when possible, dedicated to the patient and
disinfected between uses.

(ai) Clean the environment routinely.

(aj) Limit the number of visitors and family members who are in contact with the patient.
If necessary, everyone must wear PPE.

4.3 Duty Stations.

(aa) Clean & disinfect all surfaces and the equipment in the duty station at least every 8
hrs.

(ab) Avoid bringing patient case sheets and documents to the duty station.

4.4 ICU Facilities.

(aa) Severe COVID-19 patients requiring oxygen therapy and monitoring are kept in
Intensive Care Units.

(ab) Closely monitor patients with COVID-19 for signs of clinical deterioration, such as
rapidly progressive respiratory failure and sepsis and respond immediately with supportive
care interventions.

(ac) Understand the patient’s co-morbid condition(s) to tailor the management of critical
illness.

(ad) Recognise severe hypoxemic respiratory failure when a patient with respiratory
distress is failing standard oxygen therapy and prepare to provide advanced
oxygen/ventilatory support.

(ae) Ensure the following items are readily available in working condition all the time in
ICU.

S. No. Item
1. Stretcher trolley (foldable)
2. NIBP (BP Apparatus)
3. SpO2 monitor / Pulse Oximetry
4. ECG Machine
5. Ventilator with O2 source

11
 S. No. Item
6. Defibrillator
7. Syringe Infusion Pump
8. Venturi mask with O2 flow meter
9. High frequency nasal cannulas
10. Ambu bag with face mask
11. ET Tube with oropharangeal airway
12. Suction apparatus with suction catheter
13. Emergency Drug Tray
14. IV Fluids
15. Nebuliser
16. Adequate PPE Items

4.5 Ambulance / Transfer Vehicle for shifting.

(aa) Disinfection of vehicle. All surfaces that may have come in contact with the patient
or materials contaminated during patient care (e.g., stretcher, rails, control panels, floors,
walls and work surfaces) should be thoroughly cleaned and disinfected using 1% Sodium
Hypochlorite solution.

(ab) Reusable patient-care equipment before use on another patient must be cleaned
with alcohol based rub.

(ac) All surfaces and equipment must be cleaned twice every day in the morning and
evening and after every use with soap/detergent and water.

4.6 Checklist for arrival & transport of patients. Ambulance staff (technicians as well as
drivers) should be trained and oriented about common signs and symptoms of COVID-19
(fever, cough and difficulty in breathing). A sample questionnaire to identify COVID-19 cases is
as follows:-

Questions Response
Has someone in your close family returned from a foreign country Yes / No
Is the patient under home quarantine as advised by local health authority? Yes / No
Have you or someone in your family come in close contact with a confirmed Yes / No
COVID-19 patient in the last 14 days?
Do you have fever? Yes / No
Do you have cough? Yes / No
Do you have sore throat? Yes / No
Do you feel shortness of breath? Yes / No

(aa) Call Centre: On receiving the call, the call centre needs to enquire following details:-

(i) Demographic details of the patient i.e., name, age, gender etc.

(ii) Symptoms of patient: Ask whether the patient is suffering from fever, cough
and difficulty in breathing.

(iii) Ask whether patient has recently returned from a foreign country.

(iv) Ask whether the patient was under home quarantine as directed by local
health administration.

12
 (v) Ask the clinical condition of patient to be transported: whether stable or critical.

(vi) Ensure that bed is available in referral hospital with supporting equipment and
needs to convey the same while making the call.

(vii) Both call centre and ambulances should always keep the updated list of
available hospitals and beds.

4.7 Red Flags for shifting patient to more intensive monitoring areas.

(aa) Trouble breathing.

(ab) Persistent pain or pressure in chest.

(ac) Confusion or inability to arouse.

(ad) Bluish lips or face.

4.8 Revision Exercises.

CPR-Basic Life Support from BFNA Précis Page No.11-16 (hands-on-trg).

13
 UNIT - II

PATIENT HANDLING AND DISASTER MANAGEMENT

5. PPE - Use and Self-Protection during Handling Casualties. PPEs are the Personal
Protective Equipment to be worn to protect from any infection. In order to protect from Corona Virus
infection the use of PPE is essential.

5.1 Different PPEs. Face Masks Gloves, Goggles / Face Slides, Gowns, Boot Covers,
Respirators / N95 Masks and Head cover.

5.2 Principles for Using PPE:-

(aa) Always clean your hands before and after wearing PPE.

(ab) PPE should be of correct size.

(ac) Always put on PPE before contact with the patient.

(ad) Remove immediately after leaving the patient care area.

(ae) Never re-use disposable PPE.

(af) Never touch PPE during patient care.

5.3 Areas where PPE are used.

(aa) Out Patient Areas. Triage Area, Accident/Emergency Area, MI Room.

(ab) Screening Area/Help Desk/Registration Counter. While providing information to

patients.

(ac) In-Patient Areas/Hospital Wards. All PPE to be used especially while caring for
isolated patients. In ICU’s use of Goggles, Face-shield, Masks, Gown, Gloves, head and
shoe cover is important as it is a high risk area.

(ad) Waiting Areas. While interacting with patients, minimum distance of 1 metre to be
maintained and mask to be used.

(ae) Mortuary. While handling Dead Body use full components of PPE.

(af) Ambulance/Transfer to designated Hospitals. Respirator/N-95 mask. Gloves to be

used.

(ag) Laboratory. Full Components of PPE to be used.

(ah) Laundry. While handling linen of COVID patients, Masks and Gloves to be worn.

(ai) Janitors. While cleaning frequently touched surfaces, floors and toilets use Masks
and gloves.

5.4 Face Mask and their disposal . Three layered disposable Surgical Masks are good
enough. However N-95 masks can also be used in highly infectious situations. For Normal use it
is not required. Discard single use mask after each use. Dispose it immediately after removal.
Gauze or cotton masks are not recommended.

5.5 Safe Techniques and Appropriate Use of PPE.

(aa) Based on exposure risk, place mask carefully to cover mouth and nose and tie
securely to minimize any gap between face and mask.

14
 (ab) While in use avoid touching the mask.

(ac) Untie the lace from behind and remove the mask by not touching the front portion.

(ad) Replace the mask If it becomes and replace it with a new mask.

(ae) Not to use mask over 4 hrs as overuse will lead to discomfort.

(af) In case of General Public, mask is required only for persons with respiratory
problems.

5.6 Removing PPE.

(aa) Removal should be done outside patients room and it should be done slowly and
carefully.

(ab) Removal is in reverse order of wearing. Mask is removed last.

(ac) First is gloves, dispose it. Then perform hand hygiene with alcohol based rub/soap
for 20 seconds.

(ad) Then remove face shield/goggles by bending forward and outward.

(ae) Remove the head cover by bending downwards and pulling off taking care of only
touching on top of the head cover.

(af) Remove gown carefully preventing contamination. First undo the waist tie, then neck
tie, pull outward away from body by only touching inner part of gown, dispose it slowly by
rolling or make a ball of it to dispose it.

(ag) Then sit down and remove boot cover slowly touching only inner aspect.

(ah) Perform hand hygiene using alcohol rub/soap.

(ai) Leave the patient care area after opening the door with elbows.

(aj) Final step is removing the mask by bending forward, pulling the lower strap then the
upper strap, without touching outer area. Pull outward and over the head.

(ak) All PPE to be disposed in yellow Bio bin.

(al) The final step is good hand wash for 20 seconds.

6. Safe Patient Handling Techniques.

6.1 Hand Hygiene.

When should you clean your hands Before After

Caring for an infected person / suspected persons Yes Yes
Switching care from one infected person to the other Yes Yes
Collection of Throat / Blood samples Yes Yes
Despatch / transportation of samples Yes Yes
Transfer of Infected person Yes Yes
Use of PPE Yes Yes
Checking temperature, pulse and BP (vital signs) Yes Yes
Medication administration Yes Yes
Touching your nose, mouth etc. Yes Yes

15
 When should you clean your hands Before After
Touching articles used by the infected person (door locks, food, Yes
switches, remote control, cell phones, watches, computers, desks, TV
etc.)
Use of Toilet Yes Yes

6.2 Hand Washing Technique.

(aa) Wash your hands frequently using soap and water.

(ab) Wet hand with water and apply enough soap to cover all hand surfaces.

(ac) Rub hand palm to palm.

(ad) Right palm over the back of left hand with interlaced finger and repeat same for right
hand.

(ae) Back of fingers, opposing palms with fingers interlocked.

(af) Rotational rubbing of left thumb clasped in right palm and repeat the same for right
thumb.

(ag) Rotational rubbing backwards and forward with clasped fingers of right hand in left
palm and left hand in right palm.

(ah) After 20-30 seconds rinse hands with water and dry thorough with a disposable
tissue.

(ai) Turn off the tap with a tissue.

(aj) Dispose the tissue in a closed bin.

(ak) If no soap and water is available, alcohol based hand rub can be used in the similar
manner as told above. However, after using alcohol rub there’s no need to wash hands
once dried.

6.3 Respiratory Hygiene / Etiquettes.

(aa) While coughing or sneezing, turn your head away from others and cover your nose
and mouth with Handkerchief/tissue.

(ab) Wash the handkerchief daily.

(ac) It is preferable to cough/sneeze into bent elbows rather than your palms.

(ad) Do not spit or shout in public place to avoid the spread of droplets.

(ae) Do not touch your eyes, nose or mouth with unclean hands.

(af) Encourage hand washing for all with respiratory symptoms.

(ag) Ensure that the surfaces and objects are regularly cleaned.

(ah) Keeps at least one meter distance away from each other if not wearing PPE.

16
17
 (Note: Techniques of Hand washing and Respiratory Hygiene is to be demonstrated and the
video of PPE removal to be shown to the class.)

7. Triage, Hospital Admission and Home-care.

7.1 Triage. Prevent overcrowding and place patients with respiratory symptoms separately.
Always take droplet and contact precautions. Ensure hand hygiene, respiratory hygiene and
wearing of mask. Maintain one way flow of patients and staff. Family members must wait
outside the triage area. Assist the health workers in the triage area and transportation of
patients.

7.2 Transportation of Infected Patients. It is recommended that transport of infectious

patients is limited to movement considered medically essential by the clinicians. Where
infectious patients are required to be transported to other units within the hospital or outside the
following precautions may be implemented:-

(aa) Infected or colonised areas of the patient’s body are covered for contact isolation.
This may include a gown and sheets.

(ab) These patients are transferred to an Isolation room for respiratory isolation. The
patient is dressed in a mask, gown and covered in sheets.

(ac) The transport personnel remove existing PPE, cleanse hands, wear new PPE and
transport the patient on a wheelchair, bed or trolley.

(ad) 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.

(ae) 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.

18
 (af) The nominated lift may be isolated from public and staff transit through access
control measures and cleaned following transit of the infectious patient.

(ag) Management on board:

(i) Measure vitals of patient and ensure patient is stable.

(ii) If required, give supplementary O2 therapy at 5 L/min and titrate flow rates to
reach target SpO2 >90%.

(iii) If patient is being transported on ventilator to a higher centre, a doctor must

accompany the patient.

(ah) Handing over the patient:

(i) On reaching the receiving hospital, the medical team will hand over the patient
and details of medical interventions if any during transport.

(ii) After handing over the patient, the PPE will be taken off as per protocol
followed by hand-washing. Use Alcohol based rub/soap water for hand hygiene.

(iii) The biomedical waste generated (including PPE) to be disposed off in a bio-
hazard bag (yellow bag). Inside would be sprayed with Sodium Hypochlorite (1%)
and after tying the exterior will also be sprayed with the same. It would be disposed
off at their destination hospital. This shall again be followed by hand-washing.

7.3 Hospital Admission. Only suspected cases or cases with symptoms and contact history
are to be admitted in the hospital. The hospitals are to be kept prepared with beds with well-
ventilated isolation facilities. Additional PPE has to be procured. Sufficient number of respiratory
support should be available. Adequate ventilator support has to be ensured. Stable patients
must be discharged or transferred. At every stage of hospital admission IPC protocol i.e.
Infection Prevention Control to be ensured.

7.4 Isolation and Quarantine. Suspected cases and already confirmed cases are to be kept
separated. Special care must be taken to avoid mixing of the cases and spreading infection.
Frequent Hand Washing has to be ensured at all stages. Limit the number of Health workers,
visitors and even family members. Avoid unnecessary transporting of suspected and infected
patients. Always wear appropriate PPE while transporting the patient.

7.5 Home Care for Suspected Cases. To be kept under Quarantine. Separate well
ventilated room to be provided. Limit the movement and number of care givers. Visitors should
not be allowed. 01 metre distance has to be maintained between any persons. All personal
items have to be separately provided. Mask to be ensured while interacting. Perform hand
hygiene after contact with the patient or their immediate environment. Used surfaces and
utensils have to be cleaned using soap or disinfectants. All clothing has to be dipped in
detergent and to be washed and dried.

8. Disaster Management.

8.1 Administrative Control. Providing adequate training to health care workers. Ensuring
adequate staff patient ratio. Carrying out health education programmes to the patients and
families and disseminating factual information to all.

8.2 The Disaster Management Act 2005. This is to manage disasters including preparation
and capacity building. A medical condition or pandemic is also involved as disaster. As part of
COVID-19 regulations, the Govt has restricted gatherings. A 21-days Lockdown has been
imposed in India by Prime Minister. During lockdown essential supplies and grocery stores,
pharmacies will be open for public. All non-essential activity will remain shut for entire period.
Lockdown is an emergency protocol that prevents people from leaving a given area. We should
stay where ever we are and abide the rules strictly.

19
 8.3 Offences and Penalties. Obstruction to any order given by Govt will cause imprisonment.
There are also Punishment for false claim, misappropriation of money or material, spreading
rumours or unwanted messages wrt COVID-19 and false warnings. All the above offences will
call for imprisonment as well as fine/penalty.

8.4 Cancellation of Non-essential Services. All non-essential services to be avoided to

break the chain of transmission of COVID-19. However, essential services like electricity, light,
grocery, sanitation, fire and emergency and hospital services are allowed to be continued.

8.5 Community Management Services. There are 24 X 7 Corona Help lies for Tri-Services.
These helplines will be able to give correct updated and scientific information to all service
personnel/families and Depts. Command-wise helpline numbers are also provided as under:

(aa) Southern Command - 020 26343188

(ab) Eastern Command - 033 22107434

(ac) Western Command - 0172 2589901

(ad) Central Command - 0522 2480727

(ae) Northern Command - 07798158770

(af) South-Western Command - 08890014418

(ag) HQ Delhi Area - 011 25683581

COVID-19 GUIDELINES ON RATIONAL USE OF PERSONAL PROTECTIVE EQUIPMENT

Based on Guidelines for Rational Use of Personal Protective Equipment issued by MoHFW on 24 Mar 2020
Patient Care Activities / Area Risk of Triple- N-95 Gloves Gown/ Goggles Head Shoe
Exposure layered Mask Coverall Cover Cover
mask
Triage Area in OPD Moderate -   - - - -
Help Desk / Registration Counter Moderate -   - - - -
Temperature Recording Station (OPD/ Moderate -   - - - -
Fly Clinic)
Holding Area/ Waiting Area Moderate -   - - - -
Doctor’s chamber in OPD Moderate -   - - - -
Clinical management in isolation rooms Moderate -   - - - -
ICU Facility/ Critical Care Ward where High -      
aerosol generating procedures are done
SARI Ward attending to severely ill High -      
patients of SARI
Sample collection/ sample testing for High -      
COVID-19
Dead body packing High -      
Dead body transport Moderate -   - - - -
Mortuary/ Dead body handling Moderate -   - - - -
Mortuary while performing autopsy High -      
Sanitary Staff Moderate -   - - - -
CSSD/Laundry handling linen of Moderate -   - - - -
COVID-19 patients
Visitors attending OPD Low  - - - - - -
Visitors accompanying patients in OP Low  - - - - - -
facility
Supportive services. Administrative, No Risk - - - - - - -
Financial, Engineering, Security etc.

20
8.6 DO’s & DON’T’s of Face Mask Handling.

(aa) Wash your hand before putting on the mask.

(ab) Make sure that it covers both mouth and nose and is not loose.

(ac) Do not touch the mask from the front, touch only from the sides.

(ad) Make sure to wash hands after changing the mask.

(ae) Change the mask every 06 to 08 hours or when it becomes moist.

(af) If using disposable mask, have a dust bin with cover and plastic bag lining to throw
the mask.

(ag) If using cloth mask wash them daily.

8.7 Revision Exercises.

(aa) Donning (hands-on training)

(ab) Doffing (hands-on training)

(ac) Oxygen delivery devices (Oxygen concentrator / Oxygen cylinder)

(ad) Oxygen delivery interfaces (Hudson’s Mask, Venturi Mask, re-breathing mask)

21
 UNIT - III

CLEANING, DISINFECTION AND WASTE MANAGEMENT

9. Bio-medical Waste (BMW) Management deals with guidelines for handling, treatment and
disposal of COVID-19 waste at Healthcare Facilities. Sample collection Centres, Laboratories,
COVID-19 Isolation wards, Quarantine Camps and Home-care.

9.1 Segregation of Bio-Medical Waste.

(aa) Bio-medical waste should not be mixed with other (general) waste.

(ab) BMW shall be segregated at point of generation.

(ac) Bags / containers should be labelled.

(ad) BMW must not be stored more than 48 hours.

(ae) Ensure no spillage while handling.

9.2 Colour Code.

(aa) Red Bag: Contaminated recyclable wastes, wastes from disposable items like IV
tubing, bottles, sets, catheter, syringes (without needles), gloves, empty used urine bags.

(ab) Translucent White Box. Sharp wastes like needles, scalpels, blades and any other
contaminated sharps.

(ac) Blue Box. Broken or discarded glass including medicine vials and ampoules.

(ad) Yellow Bag. Anatomical waste, soiled waste like cotton swabs, dressings, chemical
waste, laboratory waste and contaminated linen with blood or body fluids.

9.3 Labelling.

(aa) Label should be non-washable.

(ab) It should be prominently visible.

(ac) The label should have the date, month and year of collection.

9.4 Packing and Transportation.

(aa) Biomedical waste bags should be packed in spillage proof packing material.

(ab) Care must be taken that no spillage is there during transportation.

(ac) PPE must be worn during all stages of packing and transportation.

9.5 Disposal of BMW.

Category Treatment
Yellow Incineration
Red Shredding and re-cycling
White Sterilisation and deep burial
Blue Disinfection / re-cycle / deep burial

22
 9.6 General Guidelines to Health Care Workers while handling BMW.

(aa) As precaution double layered bags (using 2 bags) should be used for collection of
waste from COVID-19 isolation wards so as to ensure adequate strength and no-leaks.

(ab) Use a dedicated collection bin labelled as “COVID-19” to store COVID-19 waste and
keep separately in temporary storage room prior to handing over to collecting team. Bio-
medical Waste collected in such isolation wards can also be lifted directly from ward into
collection van.

(ac) Mixing of COVID-19 waste with the bio-medical waste from other wards, general
waste etc. should be avoided.

(ad) The (inner and outer) surface of containers/bins/trolleys used for storage of COVID-
19 waste should be disinfected with 1% sodium hypochlorite solution.

(ae) Biomedical Waste if any generated from quarantine centres/camps should be

collected separately in yellow coloured bags and bins.

(af) Regular sanitisation of all workers involved in handling and collection of biomedical
waste is to be ensured.

(ag) Workers shall be provided with adequate PPEs including three layer masks, splash
proof aprons/gowns, rubber gloves, gum boots and safety goggles.

(ah) Vehicle should be sanitised with sodium hypochlorite or any appropriate chemical
disinfectant after every trip.

(ai) Do not allow any worker showing symptoms of illness to work at the facility.

10. Prevention of Environmental Contamination.

10.1 Environment Cleaning, Disinfection and BMW Management.

(aa) Ensure that the environment is clean and disinfection procedures are followed
consistently and correctly.

(ab) Thorough cleaning of surfaces with water and detergent and applying commonly
used hospital disinfectants.

(ac) Medical devices, equipment, laundry, food service utensils and medical waste
should be managed according to routine procedures.

10.2 Infection Prevention and Control Strategies.

(aa) Applying standard precautions for all patients.

(ab) Ensuring triage.

(ac) Practice early recognition of infection and source control.

(ad) Additional precautions for suspected cases.

(ae) Ensure Environmental Hygiene.

10.3 Standard Precautions.

(aa) Hand Hygiene.

(ab) Respiratory Hygiene.

23
 (ac) PPE according to the risk.

(ad) Cleaning and disinfection of patient care equipment.

(ae) Safe handling of soiled linen.

(af) Waste management.

10.4 Breaking the chain of transmission.

For an infection to spread, the agent, reservoir, port of entry and port of exit and
susceptible host is to be linked. Breaking any one link will stop the disease transmission.
Promoting hand hygiene, respiratory hygiene, use of PPE and social distancing will break the
chain of transmission of the virus.

11. General Guidelines during Casualty Management.

(aa) Ensure COVID patient is provided with patient dress and mask at the earliest.

(ab) Educate the patient about hand hygiene and cough etiquettes.

(ac) Take blood and any other samples of the patients immediately on arrival as advised.

(ad) Follow guidelines for sample collection and transportation.

(ae) Monitor vital signs of the admitted patients.

(af) Immediately inform any worsening signs and symptoms.

(ag) Ensure that all patients have taken their medicines on time.

(ah) Wear proper PPE when you are in close contact with patients and observe hand
hygiene.

(ai) Duty staff will discard their PPE on completion of their duty hours in proper BMW
Bins.

(aj) All frequently touched areas of the wards (doorknobs, tables, switches, arm rests
etc.) will be disinfected with 1% Sodium Hypochlorite. 70% Alcohol can also be used for
surfaces and skin disinfection.

(ak) Patients admitted in wards will discard clothes into a large bucket with 1% sodium
hypochlorite solution, these will then be sent to a separate laundry where they will not be
mixed with clothes of patients from other wards.

(al) Strict measures on following social distance, restriction of visitors, cleaning utensils,
laundry, medical supplies and food services to be implemented.

(am) Clean & disinfect high touch surfaces daily in household common areas.

12. Methods of Cleaning and Disinfection of Articles.

12.1 Methods of Disinfection.

S No Articles Methods
1. Thermometer Single use should be practiced if not possible disinfect
with 70% alcohol or impregnated wipes for each use
2. BP Apparatus/Cuffs
3. Stethoscope

24
 S No Articles Methods
4. Oxygen Masks/Airway Wash Sleeve with soap and water weekly In between
patients disinfect with 70% alcohol or impregnated
wipes to clean tubing and inflation bladder
5. Trolley Washing with soap and water after each use and
carbolise (70% isopropyl alcohol) before each use.
(clean contact points only)
6. Soiled bedding Wash under with hot water, no machine washing, dip in
7. Patient linen/ towel 70% alcohol or 05% Sodium Hypochlorite solution
before washing
8. Patient unit/room, IV Clean twice daily and after discharge. (Detergent +
stand, fan, light switch, disinfectant)
bedside locker and
beds, IO charts
9. Patient Utensils Wash with soap and water before and after each use
wearing gloves
10. Cleaning of Surfaces Wet mopping every four hourly with antiseptic lotion
with alcohol based No brooming or dry dusting to be
done
11. Spill Management Wear gloves and other PPE. Disinfect and clean with
1% Hypochlorite solution
12. Patient’s Room and Clean and disinfect all surfaces using Disinfectant
Bedding after Discharge/ solution
Transfer

Surface disinfectants recommended for use in the Armed Forces are cresol black and
chlorine containing compounds (bleaching powder 30%). The recommended dilutions of 01%
and 0.5% hypochlorite to be prepared from 30% bleaching powder.

12.2 Guidelines for Preparation of 1% Sodium Hypochlorite Solution.

Product Available Cl Method of Preparation

Sodium hypochlorite - liquid bleach 3.5% 1 part bleach in 2.5 parts water
Sodium hypochlorite - liquid 5% 1 part bleach in 4 parts water
NaDCC* powder 60% 17 grams in 1 litre water
NaDCC* tablet (1.5 g/tablet) 60% 11 tablets in 1 litre water
Chloramine powder 25% 80g in 1 litre water
Bleaching powder 25-33% 25-30g in 1 litre water
Any other As per manufacturer’s instructions
* NaDCC - Sodium Dichloro-isocyanurate

12.3 Revision of Exercises.

(aa) Preparation and procedure of surface disinfection (hands-on training).

(ab) Vital parameters (TPR, BP, SpO2 monitoring) (hands-on training).

(ac) Pulse oxymetry monitoring (hands-on training).

25
 UNIT - IV

COMMUNITY PREVENTION, STRESS MANAGEMENT AND GOVT INITIATIVES

13. Instructions / Health Education for Caretakers.

13.1 Role of Nutrition. Proper nutrition and hydration are vital. People who eat a well-
balanced diet tend to be healthier with stronger immune systems and lower risk of chronic
illnesses and infectious diseases.

(aa) Eat a variety of fresh and unprocessed foods every day to get the vitamins,
minerals, dietary fibre, protein and antioxidants your body needs.

(ab) Drink enough water every day (8-10 glasses of water), preferably warm water. Do
not let your throat to get dry. You can also consider lemon juice (diluted in water and
unsweetened), tea and coffee but be careful not to consume too much caffeine, and avoid
sweetened fruit juices, syrups, fruit juice concentrates, fizzy and still drinks they all contain
sugar.

(ac) Avoid sugar, fat and salt to significantly lower your risk of overweight, obesity, heart
disease, stroke, diabetes and certain types of cancer.

(ad) Eat fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains, foods
from animal sources (e.g. meat, fish, eggs and milk) and green leafy vegetables.

(ae) For snacks, choose raw vegetables and fresh fruit rather than foods that are high in
sugar, fat or salt.

(af) Do not overcook vegetables and fruit as this can lead to the loss of important
vitamins.

(ag) When using canned or dried vegetables and fruit, choose varieties without added
salt or sugar.

(ah) Eat moderate amounts of fat and oil.

(ai) Choose fresh fruits instead of sweet snacks such as cookies, cakes and chocolate.

(aj) Avoid eating out, to reduce your rate of contact with other people and lower your
chance of being exposed to COVID-19.

(ak) Avoid eating food while you are involved in patient care, take a break, follow hand
hygiene and then eat your food.

(al) Practice good food handling practices.

13.2 Common Food Myths related to COVID-19.

(aa) Consuming Chinese food spreads COVID-19 is the common food myth which is not
true.

(ab) COVID-19 does not spread through food. However, recent research suggested that
novel corona virus can stay on surfaces (cardboard, steel, plastic etc.) for various amount
of times. So, while you can reduce the chances of exposure by practising excellent
personal hygiene, it may not be a good idea to order unhealthy or junk food all the time. A
balanced diet is recommended to keep up your immunity.

(ac) There is no sufficient evidence that garlic can boost your immunity.

(ad) Consumption of alcohol does not prevent COVID-19.

26
 (ae) Consumption of meat and meat products do not cause the disease, however safe
food handling methods to be practiced.

13.3 Self Protection.

(aa) Protect yourself and others from infection by washing your hands or using an
Alcohol Based Hand Rub (ABHR) frequently and not touching your face.

(ab) Keep your nails short so that the virus cannot hide there.

(ac) Do not shake hands with anybody.

(ad) Do not shake used or unused clothing / sheets in the air to prevent spreading of
infection.

(ae) Cover your mouth and nose with disposable tissue when coughing / sneezing.

(af) Turn away from others when sneezing and coughing.

(ag) Discard tissue immediately into a non-touch waste bin or clean them appropriately
after use.

(ah) Sneeze into your elbow if you do not have a tissue.

(ai) Perform Hand Hygiene thereafter before touching your eyes, nose or mouth.

(aj) Never spit out in open. Always spit in wash basin or a closed bin.

13.4 Recommended items to carry along with you when deployed in an affected area.

(aa) ABHR (Alcohol Based Hand Rub)

(ab) Disposable facial tissue.

(ac) Thermometer.

(ad) Disposable facial mask in case you develop any respiratory symptoms.

(ae) All articles available in the BFNA Kit.

14. COVID-19 and Mental Toll.

14.1 Stress during outbreak. No part of the world can any longer claim to be completely safe
from the corona virus outbreak that has now spread to 202 countries, infecting over 6,64.103
people in a span of just three months. While this is an effective measure to contain spread of
novel corona virus infection, we must not ignore the mental health cost involved.

14.2 Tips to remain optimistic & management of Stress for Health Workers.

(aa) It is normal to feel sad, stressed, confused, scared or angry during a crisis. Talking
to people whom you trust can help. Contact your friends and family.

(ab) If you are deployed on duty while taking care of infected patients, maintain social
contacts with loved ones at home and friends.

(ac) Don’t use smoking, alcohol or other drugs to deal with your emotions. If you feel
overwhelmed, talk to our senior or buddy while at work and opt for counselling sessions.

(ad) Get the Facts. Gather information that will help you accurately determine your risk
so that you can take reasonable precautions. Find a credible source you can trust such as
WHO website or a local or state public health agency.
27
 (ae) Limit worry and agitation by lessening the time you spend on watching or listening to
media coverage that you perceive as upsetting.

(af) Draw on skills you have used in the past that have helped you to manage previous
life’s adversities and use those skills to help you manage your emotions during the
challenging time of this outbreak.

(ag) Indoor games in small groups (maintaining social distancing) with fellow colleagues.

(ah) Music therapy / hobbies as a diversion method to cope with stress.

14.3 DO’s and DON’T’s.

(aa) Do share accurate information about COVID-19 to make people feel less stressed
and allow you to connect with them.

(ab) Do allow patients to talk to their loved ones to alleviate stress and anxiety.

(ac) Deal with those under your care with love and compassion giving hope that they will
recover.

(ad) When dealing with children, allow their parents to visit them and reassure them.

(ae) Be a role model to the patients under your care.

(af) Identify those with abnormal behaviours like excessive crying, excessive worrying,
those not eating meals, etc. and report immediately.

(ag) Don’t spread any kind of rumours to create anxiety, share only what’s factual and
important.

14.4 Counselling and Psychosocial Support. While proper nutrition and hydration improve
health and immunity, they are not magic bullets. People living with chronic illnesses who have
suspected or confirmed COVID-19 may need support with their mental health and diet to ensure
they keep in good health. Arrange for counselling and psychosocial support from appropriately
trained health care professionals and also community-based counsellors for those needing
attention. As a frontline worker, you can do your bit by early identification and prompt reporting
such cases you encounter on duty.

15. India’s Fight with COVVID-19 - Special emphasis to AFMS.

15.1 Evacuation and Quarantine.

(aa) Manesar Camp

(ab) Other centres: Kolkata, Secunderabad, Chennai, Jaisalmer, Mumbai and Suratgarh.

(ac) Addl Centres are Jodhpur. Jhansi and Jalipa.

(ad) 45 bedded isolation facility and 10 bedded ICU to be set up in all Field Hospitals.

28
 15.2 Approach of AFMS / Health Care Establishment wrt COVID-19 patients.

Appx ‘A’ to DGMS (Army) 76910/UN Occur/

Corona Virus/DGMS-5B dated 09 Mar 2020

* High risk countries include China, Republic of Korea, Islamic Republic of Iran, Italy and Japan (as on 06 Mar 2020).
# AII contacts of suspected case admitted to isolation ward in a hospital should be home quarantined. They should be tested only if they develop
symptoms. Facility based quarantine to be implemented in rare cases where large group of individuals such as an entire barrack/platoon of troops or
multiple sailors on a ship or large number of air crew are known to have been exposed to a suspected/confirmed case. In such circumstances, the facility
identified by Stn Cdr and SEMO to be used or a separate living accommodation within Unit premises can be improvised into a quarantine facility.

29
15.3 Role of BFNAs during the Outbreak.

(aa) Prevention of spread of infection.

(ab) Provision of important information / help line numbers.

(ac) Spreading key messages to deal with infection.

(ad) Assisting in actions for early detection.

(ae) Referral services of suspected cases.

(af) Keeping self safe while carrying on with assigned duties.

(ag) Health education regarding symptoms and home quarantine.

(ah) Reassurance to symptomatic patients.

(ai) Ensuring safe hand and respiratory hygiene of self and the same to public.

(aj) Ensuring proper BWM protocol.

(ak) Safe transportation of patients following guidelines.

(al) Assisting other health care workers in their service.

30
 UNIT - V
STANDARD PRECAUTIONS : DEAD BODY MANAGEMENT

16. While handling dead bodies of COVID-19 standard infection prevention control practices should
be followed by health care workers at all times. These includes:-

16.1 Standard Precautions.

(aa) Hand Hygiene.

(ab) Use of personal protective equipment (e.g. water resistant apron, gloves.

(ac) Safe handling of sharp.

(ad) Disinfect bag housing dead body instruments and devices used on the patient.

(ae) Disinfect linen. Clean and disinfect environmental surfaces.

16.2 Removal of the Body from the Isolation Room or Area. To minimise the risks of
transmission a rational approach should include staff training and education, safe working
environment, appropriate work practises and the use of recommended safety devices. The staff/
health worker identified for removal of the dead bodies should follow under-mentioned
measures:-

(aa) Before attending to the dead body the health worker should perform hand hygiene,
ensure proper use of PPE (water resistant apron, goggles, N-95 mask, gloves, shoe
cover).

(ab) All tubes, drains and catheters on the dead body should be removed.

(ac) Any puncture holes or wounds (resulting from removal of catheter, drains, tubes, or
otherwise) should be disinfected with 1% hypochlorite and dressed with impermeable
material.

(ad) Extreme caution should be exercised when removing intravenous catheters and
other devices which are sharp. They should be disposed into puncture resistant
containers.

(ae) Plug oral, nasal orifices of the dead body to prevent leakage of body fluids.

(af) If the family of the patient wishes to view the body at the time of removal form the
isolation room or area, they may be allowed to do so with the application of standard
precautions.

(ag) Place the dead body in leak-proof plastic body bag. The exterior of the body bag can
be decontaminated with 1% hypochlorite. The body bag can be wrapped with a mortuary
sheet or sheet provided by the family members.

(ah) When handling dead bodies, avoid touching own mouth, eyes or nose. Smoking,
drinking and eating is forbidden in the autopsy room, body storage and viewing areas.

(ai) The body will be either handed over to the relatives or taken to mortuary.

(aj) All used/ soiled linen should be handled with standard precautions, put in bio-hazard
bag and the outer surface of the bag disinfected with hypochlorite solution.

(ak) Examination of dead body and afterwards in dealing with waste disposal and
decontamination.

31
 (al) Used equipment should be autoclaved or decontaminated with disinfectant solutions
in accordance with established infection prevention control practices.

(am) All medical waste must be handled and disposed off in accordance with recent Bio-
medical waste management rules.

(an) The health staff who handled the body will remove personal protective equipment
and will perform hand hygiene.

16.3 Handling of Dead Body in Mortuary.

(aa) Mortuary staff should be trained in the prevention of infections handling COVID dead
body and should observe standard precautions.

(ab) Dead bodies should be stored in cold chambers maintained at approximately 4°C.

(ac) The mortuary must be kept clean. Environmental surfaces, instruments and
transport trolleys should be properly disinfected with 1% Hypochlorite solution/2.5%
Cresol.

(ad) After removing the body, the chamber door, handles and floor should be cleaned
with sodium hypochlorite 1% solution/2.5% Cresol.

16.4 Embalming. Embalming of dead body will not be allowed.

16.5 Body Bags - Specifications. Body bag in which dead body is to be transported should
have following specifications:-

(aa) Impermeable.

(ab) Leak proof.

(ac) Air sealed.

(ad) Double sealed.

(ae) Opaque.

(af) White.

(ag) U shaped with zip.

(ah) 4/6 grips

(ai) Size : 2.2 x 1.2 metres

(aj) Standards:-

(i) ISO16602:2007

(ii) ISO16603:2004

(iii) ISO16604:2004

(iv) ISO/DIS22611:2003

16.6 Transportation of Dead Body.

(aa) The body secured in a body bag, exterior of which is decontaminated poses no
additional risk to the staff transporting the dead body.

32
(ab) The personnel handling the body may follow standard precautions (surgical mask,
gloves).

(ac) The vehicle after the transfer of the body to cremation/burial staff will be
decontaminated with 1% Sodium Hypochlorite.

(ad) The discrete use of labels such as “Danger of Infection” on the dead body is
considered appropriate.

33
 UNIT - VI
EVALUATION AND DE-BRIEFING

17. Evaluation. The learning outcomes are assessed at the end of the training. The learners are to
be grouped in a batch of 15. The clinical based scenarios, 'must know’ areas and the essential skills
such as hand washing, doffing, donning, preparation of solutions, disinfection of surfaces,
transportation and health education dealt in this module to be crafted into a Objective Structured
Practical Evaluation (OSPE).

The first batch can be recruited for the OSPE stations with duration of 2½ hours with 18
stations (15 assessment station + 03 rest stations). The 06 stations dealing with essentials
skills mentioned above should be manned with trained observer. Remaining stations can be
designed as question answer (short answer/objective) in paper pencil mode. The same can be
repeated with minor changes in the successive sessions.

17.1 De-Briefing. A De-briefing session to be organised in presence of the organisational

leadership and other stake holders. The learning outcomes and its importance in the current
scenario to be reemphasised and the role played by each Battle Field Nursing Assistants. The
learners may be rewarded with a training certificate at the end of the de-briefing session.
Subsequently, the course can be dispersed after completion of essential formalities.

Note: If the target group is not trained in Battle Field Nursing Assistant Course then appropriate
course content from BFNA Training course has to be incorporated while administering this module.
The areas earmarked as “hands-on training” to be practised in presence of trained health care
professional.

34