INDUS HEALTH NETWORK

COVID
MANAGEMENT
GUIDANCE
FOR ADULTS

indushospital indus_hospital theindushospital the-indus-hospital The Indus Hospital

CONTRIBUTIONS
Developed by Dr. Samreen Sarfaraz (Consultant Adult Infectious Diseases) at the Indus Hospital, Karachi with
contributions from Dr. Shamvil Ashraf (Executive Director Indus Health Network) and Dr. Imran Iftikhar (Consultant
Cardiology).

We are thankful to Dr. Quratulain Shaikh (Epidemiologist Indus Hospital Research Center; IHRC) for formatting,
reviewing and proof reading and Dr. Uzair Mahmood (Research Associate, IHRC) and Mr. Mohammad Fahad
(Faculty Support Officer) for their support in formatting and editing. Sada Abbas, Assistant Manager, CRD
helped with the designing of the guidelines.
CONTENTS
1 Screening and triage
1.1 Case definition of a COVID-19 suspect
1.2 IHN self-screening tool
2 Personal protective equipment according to risk
3 Management of patients with suspected/confirmed COVID-19
3.1 Categorization of adult cases
3.2 Criteria for admission of COVID-19 suspected or confirmed patients
3.2.1 Symptoms
3.2.2 Clinical criteria
3.3 Management of covid patients
3.3.1 Role of prophylaxis
3.3.2 Management of asymptomatic COVID -19 cases
3.3.3 Management of mild and moderate cases
3.3.4 Management of severe and critical disease
3.3.5 Additional drugs to consider in severe ards
3.3.6 Discharge criteria for severe cases
4 Resuscitation of COVID-19 patients in hospital
5 Quarantine and isolation of covid suspects
5.1 Quarantine
6 Isolation of probable or confirmed covid patients
6.1 Guidelines for hospital or dedicated facility isolation
6.1.1 Discontinuation of isolation
6.2 Guidelines for home isolation
6.2.2 Indications
6.2.2 Guidelines for home isolation of suspected case
6.2.3 Guidelines for caregivers
7 References
Annexure 1A Pathway for the management of suspected or diagnosed COVID-19
patient at the indus health network
Annexure 1B Treatment algorithm for hospitalized patients with severe COVID-19
Annexure 1C Pathway of discontinuing isolation in COVID-19 patients
Annexure 2A CPR of COVID-19 patients
Annexure 2B High quality CPR components-covid 19
Annexure 3 Instructions for home management of COVID-19 suspects
1. SCREENING AND TRIAGE

1.1 CASE DEFINITION OF A COVID-19 SUSPECT

Testing should be performed using PCR of a nasopharyngeal or oropharyngeal swab.Serology (IgM/IgG tests)
are NOT recommended as primary means for diagnosis. A negative IgM/IgG must be confirmed with a PCR.
Given the limited availability of tests, a tiered approach is recommended. Priority for testing is given to Tier-1
cases. These definitions will change as the outbreak progresses and testing capabilities are expanded.

• Tier-1: High level of suspicion of COVID-19. Always test

• Tier-2: Low level of suspicion of COVID-19.Test only if there is strong suspicion (at physician discretion).
If testing is not being performed, then home isolation until resolution of symptoms is recommended.

Tier – 1: High level of suspicion of COVID-19

• International travel in the last 14 days.
• Household contact with an asymptomatic international traveler.
• Close* or household contact with a confirmed or probable COVID-19 patient.
• Engaged in public dealing e.g. bank teller, general physician.
• Has attended a large religious or social gathering recently.
• Health care worker involved in the care of a confirmed COVID-19 patient.
• Health care worker involved in the care of a patient with pneumonia of unspecified
FEVER/ etiology.
COUGH/ • Healthcare worker working at point of Entry like outpatient department, emergency,
reception/registration counters.
SOB • Caregiver of a person with pneumonia of unspecified etiology.

Tier – 2: Low suspicion of COVID -19

• Intercity travel in the last 14 days.
• Close* or house hold contact with an asymptomatic domestic traveler.
• Daily or very frequent use of public transport associated with crowding
e.g. crowded buses.

*Close contact: 15 min face to face contact within 1 m

• Other Tier-1 Conditions:

• Patients admitted in the hospital with unexplained viral pneumonia or respiratory failure, regardless of
travel history or close contact with suspected or confirmed COVID-19 patients.
• Asymptomatic close OR household contact of a confirmed COVID-19 patient, as part of contact
tracing.

• Other Tier-2 Conditions:

• Patients with upper respiratory tract symptoms, body aches or other non-specific symptoms with or
without risk factors of travel or contact with asymptomatic travelers or travelers with mild symptoms.

1.2 IHN SELF-SCREENING TOOL

IHN has developed a self-screening tool for COVID-19 available in English and Urdu available at: http://-
Covid19.tih.org.pk
http://covid19.tih.org.pk/urdu.html
2. PERSONAL PROTECTIVE EQUIPMENT
ACCORDING TO RISK

SURGICAL N95 EYE

PERSON SITUATION NONE GLOVES GOWNS
MASK MASK SHIELD

Caring for suspected/

Non HCW √
confirm patient

Suspected √

Patients Confirmed √

In single room isolation √

Taking care of suspected or

confirmed patient regardless √ √ √ √
of need for suctioning

HCW Collecting NP swab √ √ √ √

While removing linen/waste √ √ √

A detailed PPE guide for IHN employees has been developed as a separate document

3. MANAGEMENT OF PATIENTS WITH SUSPECTED/

CONFIRMED COVID-19

3.1 CATEGORIZATION OF ADULT CASES

3.1.1 ASYMPTOMATIC CASES
Nasopharyngeal RT- PCR positive for SARS CoV2 but having NO symptoms.These patients shed the virus and can
transmit the infection to others.

3.1.2 MILD CASES

Presence of symptoms consistent with COVID such as fever, fatigue, cough (with or without sputum production),
anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, loss of smell or taste & headache
without any:

i. Hemodynamic compromise.
ii. Need for oxygen.
iii. Chest infiltrates

3.1.3 MODERATE CASES

Patients with fever and respiratory symptoms, with:

i. CXR showing mild chest infiltration.

ii. Mild hypoxia, (oxygen saturation ≤ 94%).
iii. Fulfilling criteria for admission due to other reasons e.g. high spiking fevers for at least 3 days,
excessive vomiting, dehydration etc.
3.1.4 SEVERE CASES
Bilateral chest infiltrates with oxygen saturation < 93% but not meeting criteria for critical cases

3.1.5 CRITICAL CASES

Presence of any of the following with COVID:

i. Respiratory rate > 30 breaths/min.

ii. Severe respiratory distress (cannot speak in sentences).
iii. Central cyanosis.
iv. Confusion, agitation, restlessness.
v. CURB 3 or 4 score.
vi. qSOFA score 2 or more.
vii. Widespread infiltrates on CXR.
viii. PaO2/FiO2 ratio less than 300 or PaO2 less than 65 or Rising PaCo2.
ix. Evidence of heart failure (Raised JVP, Gallop rhythm).
x. Signs of shock: Delayed capillary refill; Cold, clammy peripheries; Mottled skin; Systolic BP less than 90
or less than 40mm Hg of baseline in hypertensive; Urine output < 0.5 ml/kg/hr.
These patients are frequently in ARDS, which is described below

3.1.6 COVID -19 WITH ACUTE RESPIRATORY DISTRESS SYNDROME

Onset

Within 7-10 days of COVID infection. Manifested as new or worsening respiratory symptoms.

Features

Respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echo-
cardiography) to exclude hydrostatic cause of infiltrates/edema if no risk factor present.

Chest imaging

(radiograph, CT scan, or lung ultrasound):Bilateral opacities, not fully explained by volume overload, lobar or
lung collapse, or nodules.

Severity of ARDS:

i. Mild ARDS: PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O, or non- ventilated).
ii. Moderate ARDS: PaO2/FiO2 ≤ 200 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated).
iii. Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated).
Note: When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS (including in non-ventilated patients).
3.2 CRITERIA FOR ADMISSION OF COVID-19 SUSPECTED OR
CONFIRMED PATIENTS
3.2.1 SYMPTOMS

1. Hemodynamically unstable.
2. Spiking high fevers.
3. Dyspnea.
4. Unable to tolerate orally.
5. Profuse vomiting or diarrhea.
6. Dehydrated.
7. Complaining of decreasing urine output.
8. Listlessness.
9. Severe co-morbid conditions: heart failure decompensated liver disease, structural lung damage/
chronic lung disease, uncontrolled diabetes, CKD.
10. Immunosuppressed (e.g. HIV, on long-term steroids or immunosuppressive).
11. Pregnancy (Even if stable and in home isolation, close monitoring required )
12. Age > 65 years (Even if stable and in home isolation, close monitoring required )
13. Homeless patient or who lacks a carer (but if stable , admit in dedicated institution rather

3.2.2 CLINICAL CRITERIA

1. Vitals:
a. Pulse > 100.
b. B.P < 90 systolic or < 40 mm Hg below baseline in hypertensive, diastolic < 60mm Hg.
c. R.R > 24/min.
d. SpO2 O2 sat < 94%.
e. Temperature 101F or more.
2. GCS < 15.
3. Agitation, restlessness.
4. Central cyanosis.
5. Staccato speech at rest -Cannot complete sentences at rest.
6. Dehydration.
7. Signs of shock:
a. Delayed capillary refill.
b. Cold, clammy skin.
c. Mottling.
d. Urine output < 0.5 ml/kg/hr.
8. Abnormal chest findings:
a. Consolidation/localized crepitation.
b. Decreased air entry.
i. Findings of effusion or wheezing.
9. Signs of heart failure (raised JVP, edema, gallop rhythm)
10. QSOFA 2 or more.
3.3 MANAGEMENT OF COVID PATIENTS

3.3.1 ROLE OF PROPHYLAXIS:

There is no role of prophylactic Chloroquine or Hydroxychloroquine at this time. These drugs have significant
side effects.Moreover, cases are emerging globally of acquiring COVID-19 infection despite prophylaxis.

3.3.2 MANAGEMENT OF ASYMPTOMATIC COVID -19 CASES:

1. Placement: Can be managedin home isolation if minimum requirement of home isolation met. Educate
patient about symptoms and encourage self-reporting if he develops symptoms on a dedicated help
line.
OR
2. Monitored in a dedicated isolation facility (as opposed to hospital) if requirements of home isolation
are not met.

Criteria for home isolation include (must fulfill all of the below):

1. Those with a separate room to stay in

2. Those consenting for isolation
• No specific treatment (including Chloroquine or Hydroxychloroquine) is recommended

Discontinuing Isolation

Discontinuing Isolation: Repeat NP PCR on day-7 and discontinue isolation if negative. If NP PCR is still positive
on day-7, repeat NP PCR after another 5 days and discontinue isolation if it is negative (Appendix -1).

3.3.3 MANAGEMENT OF MILD AND MODERATE CASES

MILD CASES MODERATE CASES

PLACEMENT • Can be placed in home isolation if • Should always be admitted in a hospital

minimum requirements of home and monitored for deterioration.
isolation met or dedicated isolation • Ideally should be placed in a single
facility if not met to decreaseburden on room but may be cohorted with
health care. confirmed positive patients, keeping a
• If home isolated, the patient should be distance of 6ft between beds.
encouraged to self- report symptoms on • Suspected and confirmed COVID
a dedicated help line and regular patients should never be cohorted
monitoring by telemedicine should be together.
done throughout the period of isolation. • Contact and droplet precautions should
Patients older than 65 years of age, be instituted.
immunocompromised e.g. HIV or on
steroids, having comorbids like DM,
structural lung disease, IHD, CKD or CLD
should be closely monitored OR even
admitted to hospital if capacity allows.
• Ideally should be placed in a single
room but may be cohorted with other
confirmed COVID patients, keeping a
distance of 1 meter between beds.
• Suspected and confirmed COVID
patients should never be cohorted
together.
• Contact and droplet precautionsshould
be instituted.-(appendix -1)
 MILD CASES
INVESTIGATIONS • CBC.
• Electrolytes and serum creatinine.
• CXR at baseline.
• Further monitoring based on
comorbidities.
TREATMENT • Supportive care only. No specific
treatment (including
Chloroquine or
Hydroxychloroquine) is
recommended.
• Acetaminophen for fever.
• Oral hydration in case of
diarrhea.
• Anti-histamines for rhinorrhea.
• There is a theoretical risk with
the use of NSAIDS or ACE-
inhibitors in COVID-19.
However, clinical data regarding
this is lacking and at this point, a
strong recommendation to avoid
or to continue these
medications cannot be made
MODERATE CASES
• CBC.
• Electrolytes and serum creatinine.
• CXR (repeated if any evidence of clinical
worsening and before discharge.
• Further monitoring based on
comorbidities.
• Additional investigations to be
considered:
CRP (repeated if any evidence of
clinical worsening)
LDH
ABGs
Lactate
Ferritin
ECG (if age>40 years or if clinically
indicated)
Cardiac enzymes (if indicated)
Liver function tests
Pro-calcitonin
Blood cultures and any other relevant
cultures.
• Supportive oxygen therapy via nasal
cannula.
• Acetaminophen for fever control.
• Intravenous fluids if needed.
• In case of lobar infiltrates, antibiotics
may be considered especially if
associated with high white count.
• There is no current evidence from
studies to recommend any specific
anti-COVID-19 treatment for patients
with confirmed COVID-19 infection.
• Based on the best available evidence,
treatment with either of the following
can be started:
Chloroquine 500 mg BD for 10 days
OR
Hydroxychloroquine sulfate 400mg BD
on day one, followed by 200 mg, three
times per day during ten days
• On therapy, QT-interval must be
monitored.
• Avoid other medications which
prolong the QT-interval.
 MILD CASES
DISCHARGE • Isolation precautions can be discontin-
CRITERIA ued and cure declared once all the
following conditions have been met:
Resolution of fever without the use of
antipyretics.
Improvement in respiratory
symptoms (e.g., cough, shortness of
breath).
Two consecutive negative PCR
tests collected one day apart.
NOTE: Repeat PCR testing should be done
5 days after resolution of the symptoms. If
the patient is still positive, a repeat sample
should be obtained 5 days later.
MODERATE CASES
• Isolation precautions can be discontin-
ued and cure declared once all the
following conditions have been met:
Resolution of fever without the use of
antipyretics.
Improvement in respiratory symptoms
(e.g., cough, shortness of breath).
SpO2 >94% without assisted O2.
Imaging shows obvious improvement.
There are no comorbidities that require
hospitalization.
Two consecutive negative PCR tests
collected one day apart
NOTE:
• Repeat PCR testing should be done 5
days after resolution of the symptoms. If
the patient is still positive, a repeat
sample should be obtained 5 days later.
• If the patient has become asymptomatic
after treatment but the PCR is positive,
he/she may be moved to home isolation
3.3.4 MANAGEMENT OF SEVERE AND CRITICAL DISEASE

• Admit the patient in airborne isolation with strict PPE.

• Initial investigations and supportive care should proceed as in moderate disease.
• Additional investigations may be required according to the respiratory status of the patient e.g arterial
blood gases and lactate levels.
• Prophylactic anti co-agulation with LMWH or heparin
• Give empiric antibiotics if secondary bacterial pneumonia is suspected (e.g raised white blood cell
counts or elevated pro-calcitonin).
• Prone ventilation for 12–16 hours per day is recommended.
• In patients with ARDS who are intubated, use conservative fluid management.
• Diuretics may be needed in myocarditis.
• Implement mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight, PBW)
and lower inspiratory pressures (plateau pressure < 30 cmH2O).
• In addition to other supportive measures, consider any one of HCQ or CQ along with methylprednisolone.
Most effective before day 12 of illness

DRUG DOSE & DURATION MECHANISM

Tab • Loading dose 400 mg BID • Prevents acidification of endosomes

Hydroxychloroquine* (HCQ) followed by 200 mg TDS x
5 -10 days.
• 3 times more
potent than CQ in vitro.
interrupting cellular functions and
replication.
• Prevents viral entry via ACE2 binding.
• Reduction of viral infectivity x Immuno-
modulation.

Tab 500mg BD x 10 days. Same.

Chloroquine Phosphate (CQ)

Methylprednisolone 1-2 mg/kg in divided doses for (Add in addition to CQ or HCQ)

5-7 days Helps in reducing inflammatory response
during the cytokine storm

* Side effects: QTC prolongation, rash, retinopathy (rare)

3.3.4.1 ADDITIONAL DRUGS TO CONSIDER IN SEVERE ARDS

These medications have:

• Considerable adverse effects,

• Limited available
• Unclear efficacy.
Consultation with an Infectious Diseases Specialist is mandatory prior to prescribing

DRUG DOSE MECHANISM SIDE EFFECTS

Intravenous Loading dose on the first
Remdesivir (if available) day of 200 mg followed by
a maintenance dose of 100
mg once daily x 5-
10 days.
Viral RNA dependent RNA Nausea, vomiting, Elevat-
polymerase inhibitor ed liver enzymes Rectal
In-vitro data reveals potent bleeding
SARS-COV-2 inhibition and
early clinical data shows
possible benefit.

Intravenous 8mg/kg Single maximum IL-6 receptor antagonist Headache

Tocilizumab* dose 800 mg. may attenuate cytokine Elevated liver enzymes
Repeat dose may be given release in patients with Infusion reactions
12 hrs later severe disease Retrospec- (e.g. flushing, chills)
tive data suggest possible
benefit (clinical trials
ongoing)

Given only if there is

cytokine storm as
evidenced by:
High LDH, ferritin, CRP
, IL-6 levels & NLR> 3.14

DO NOT give if:

-suspicion of superadded
bacterial infection or TB is
present.

Tab 400/100mg BID x 14 Viral protease inhibitor. Not recommended as

Lopinavir/ritonavir days. In-vitro data reveals potent monotherapy.
(LPV/r) Check HIV status and only SARS- COV-2 inhibition Limited availability, poor
prescribe in those negative tolerability (such as GI side
for HIV effects) and recent data
demonstrated question-
able clinical efficacy

Other investigational modalities with questionable efficacy and poor safety or efficacy data at this point in time:

i. Convalescent plasma therapy.

ii. IV immunoglobulins.
iii. Using azithromycin alone or in combination with Hydroxychloroquine.
iv. Ivermectin.
v Sarulimab.
vi. Therapeutic anti-coagulation
3.3.4.2 DISCHARGE CRITERIA FOR SEVERE CASES

All of the following criteria must be met for 5 days before repeat PCR is sent:

i. Remains afebrile
ii. No respiratory distress at rest, R.R < 22/min.
iii. Improvement of respiratory symptoms.
iv. Lung imaging shows obvious improvement.
v. SpO2 >94% without assisted O2.

2 repeat PCR sent 24 hours apart should be negative before patient is declared cured and isolation discontinued

Note: If the patient has become asymptomatic after treatment symptoms but the repeat swab is positive, the
patient may be moved to home isolation and repeat swab sent 5 days later.

4. RESUSCITATION OF COVID-19 PATIENTS IN HOSPITAL

i. Recognize cardiac arrest. Look for the absence of signs of life and normal breathing. Feel for a carotid
pulse. Do not listen or feel for breathing by placing your ear and cheek close to the patient’s mouth.
ii. Health care provider requires a gown, eye protection, gloves and N-9 mask before starting chest
compressions. Start compression-only CPR and monitor the patient’s cardiac arrest rhythm as soon as
possible.
iii. Avoid mouth-to-mouth ventilation and the use of a pocket mask. If the patient is already receiving supple-
mental oxygen therapy using a facemask, leave the mask on the patient’s face during chest compressions
as this may limit aerosol spread. If not in situ, but one is readily available, put a mask on the patient’s face.
Restrict the number of staff in the area.
iv. Defibrillate shockable rhythms rapidly - the early restoration of circulation may prevent the need for
airway and ventilator support.
v. Airway interventions e.g. supraglottic airway (SGA) insertion or tracheal intubation must be carried out by
experienced individuals. Individuals should use only the airway skills (e.g. bag-mask ventilation) for which
they have received training.
vi. Dispose of, or clean, all equipment used during CPR following the manufacturer’s
recommendations and Hospital guidelines.
vii. Remove PPE safely to avoid self-contamination and dispose of clinical waste bags as per guidelines.
Hand hygiene has an important role in decreasing transmission. Thoroughly wash hands with soap and
water; alternatively, alcohol hand rub is also effective.
viii. Post resuscitation debrief is important and should be planned.
5. QUARANTINE AND ISOLATION OF COVID SUSPECTS

5.1 QUARANTINE
Separation and restriction of movement of persons who are exposed to a patient with COVID-19 disease to see
whether they develop the infection. Quarantine may be at home or in a facility
Duration: 14 days.

5.1.1 QUARANTINE FACILITY LEVEL

1. INFRASTRUCTURE
i. No universal guidance regarding the infrastructure for a quarantine facility
ii. Preferably single room for a patient with an attached bathroom should be provided
iii. If patients are cohorted there should be a 3ft distance between them with strict instructions not to
intermingle so as not to further enhance potential transmission
iv. Living placement should be monitored for cleanliness
v. Follow up by telemedicine / HCW to detect appearance of illness. Self-reporting of symptoms
encouraged

2. ACCOMMODATION AND SUPPLIES

i. Should be provided with adequate food and water, appropriate accommodation including sleep-
ing arrangements and clothing, protection for baggage and other possessions, appropriate
medical treatment, means of necessary communication if possible, in a language that they can
understand and other appropriate assistance.
ii. A medical mask is not required for those who are quarantined

3. COMMUNICATION
i. Establish appropriate communication channels to avoid panic and to provide appropriate health
messaging so those quarantined can seek timely appropriate care when developing symptoms.

4. RESPECT AND DIGNITY

i. Travelers should be treated with respect for their dignity, human rights and fundamental freedom
and minimize any discomfort or distress associated with such measures.

5.1.2 HOME QUARANTINE:

1. RECOMMENDATIONS FOR PERSONS UNDER QUARANTINE

i. Stay in a well-ventilated single room.
ii. Avoid gatherings and crowded spaces.
iii. Must stay at home.
iv. Maintain a distance of at least 1 meter with family members.
v. Perform hand hygiene frequently.
vi. Alcohol-based hand rubs can be used if hands are not visibly soiled. Use soap and water when
hands are visibly soiled.
vii. Cover nose and mouth while sneezing and coughing with flexed elbow or paper tissue, dispose
the tissue immediately after use and perform hand hygiene.
viii. Avoid touching the face.
ix. Dustbin should be lined with a bag and the bag tied tightly before throwing.
x No need for the person under quarantine or household members to wear a mask.
xi. Watch for Signs and Symptoms. If fever, cough or shortness of breath develop then inform on
hospital help line.
xii. Dedicated Linen and utensils.
xiii. Routine cleaning of the house is recommended.
5.1.3 MONITORING OF QUARANTINED PEOPLE

1. SELF-MONITORING OF QUARANTINED PERSONS

i. People should monitor themselves for fever by taking their temperatures twice a day and remain
alert for a cough or difficulty breathing.
ii. If they feel feverish or develop measured fever, cough, or difficulty breathing they should self-isolate,
limit contact with others, and contact the helpdesk

2. ACTIVE MONITORING OF QUARANTINED PEOPLE

i. Provincial health department assumes responsibility for establishing regular communication with
potentially exposed people to assess for the presence of fever, cough, or difficulty breathing.
ii. They should be followed up every 48 hours to assess for the period of the quarantine.

6. ISOLATION OF PROBABLE OR CONFIRMED COVID PATIENTS

Separation of patients infected with proven or suspected COVID-19 to prevent the spread of the infection.
Isolation may be at home or in the hospital.

6.1 GUIDELINES FOR HOSPITAL OR DEDICATED FACILITY ISOLATION

1. Patients will be isolated in COVID Unit at TIH Korangi campus or other dedicated isolation center-
swhere droplet and airborne transmission risks can be minimized.
2. Ensure either single-use/disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs,
and thermometers).
3. If equipment needs to be shared, clean and disinfect it between use for each patient (e.g., by using
ethyl alcohol 70%).
4. Staff taking care of these patients should strictly observe contact and air-borne precautions
5. If negative pressure isolation is not available (as in our set up) then place in a room with ample ventila-
tion. Do not place patient in a room in which air is recirculated (e.g. centrally air-conditioned area
without special air handling).
6. Ensure adequate environmental cleaning consistently and correctly.
7. Manage laundry, food service utensils and medical waste in accordance with safe routine procedures.
8. Avoid moving and transporting patients out of their room or area unless medically necessary.
i. Use designated portable X-ray equipment and/or other designated diagnostic equipment, when-
ever possible.
ii. If transport is required, use predetermined transport routes to minimize exposure for staff, other
patients and visitors.
iii. The patient should use a medical mask during transport
iv. Ensure that HCWs who are transporting patients perform hand hygiene and wear appropriate PPE
v. Notify the area receiving the patient of any necessary precautions as early as
possible before the patient’s arrival
9. Single room is preferred.
10. If not available, patients can be cohorted together in a dedicated ward.
11. Maintain at least 1-meter distance between patients.
12. All health care workers must take the following precautions when entering the room/ward.
i. Wear an N-95 mask at all times during patient care
ii. Observe STRICT hand hygiene
iii. Avoid touching eyes or the mask
iv. Wear clean, long sleeve non-sterile gowns
v. Remove PPE before leaving the room/ward and immediately perform hand hygiene
vi. Wear an N-95 mask at all times during patient care
6.1.1 DISCONTINUATION OF ISOLATION

i. Patients can be moved out of isolation only when symptoms improve AND two
consecutive swabs (sent one day apart) are negative
ii. If the patient has become asymptomatic after treatment but the swab is positive, the patient may be
moved to home isolation

6.2 GUIDELINES FOR HOME ISOLATION

(ANNEXURE -3)

6.2.1 INDICATIONS:

Home Isolation may be considered in the following patients:

i. Those with a separate room to stay in

ii. Those with mild or asymptomatic disease
iii. Those consenting for isolation

6.2.3 GUIDELINES FOR HOME ISOLATION OF SUSPECTED

Home Isolation may be considered in the following patients:

i. Place the patient in a well-ventilated single room (i.e., with open windows and an open door).
ii. Limit the movement of the patient in the house and minimize shared space.
iii. Ensure that shared spaces (e.g., kitchen, bathroom) are well ventilated (e.g., keep windows open).
iv. Household members should stay in a different room
v. Limit the number of caregivers.
vi. Ideally, assign one person who is in good health with no underlying chronic or immunocompromising
conditions.
vii. Visitors should not be allowed until the patient has completely recovered and has no signs and
symptoms.
viii. Perform hand hygiene after any type of contact with patients or their immediate environment.
ix. Hand hygiene should also be performed before and after preparing food, before eating, after using
the toilet and whenever hands look dirty.
a. If hands are not visibly dirty, an alcohol-based hand rub can be used.
b. For visibly dirty hands, use soap and water.
c. When washing hands with soap and water, it is preferable to use disposable paper towels to dry
hands.
d. If these are not available, use clean cloth towels and replace them when they become wet.
x. The patient must use their own towel.
xi. A medical mask should be provided to the patient and worn as much as possible.
xii. Mouth and nose should be covered with a disposable paper tissue when coughing or sneezing and
discarded after use.
6.2.4 GUIDELINES FOR CAREGIVERS

i. Should wear a surgical mask that covers their mouth and nose when in the
same room as the patient.
ii. Masks should not be touched or handled during use.
iii. If the mask gets wet or dirty from secretions, it must be replaced immediately with a new clean, dry
mask.
iv. Remove the mask using the appropriate technique – that is, do not touch the front, but instead untie it.
Discard the mask immediately after use and perform hand hygiene.
v. Avoid direct contact with body fluids, particularly oral or respiratory secretions, and stool.
vi. Use disposable gloves and a mask when providing oral or respiratory care and when handling stool,
urine and other waste.
vii. Perform hand hygiene before and after removing gloves and the mask.
viii. Do not reuse masks or gloves.
ix. Use dedicated linen and eating utensils for the patient
x. Items should be cleaned with soap and water after use and may be re-used instead of being
discarded.
xi. In the room where the patient is being cared for, clean and disinfect daily surfaces that are frequently
touched, such as bedside tables, bedframes and another bedroom furniture.
xii. Regular household soap or detergent should be used first for cleaning, and then, after rinsing, regular
household disinfectant containing 0.5% sodium hypochlorite (i.e., equivalent to 5000 pm or 1-part
bleach to 9 parts water) should be applied.
xii. Clean and disinfect bathroom and toilet surfaces at least once daily
xiv. Regular household soap or detergent should be used first for cleaning, and then, after rinsing, regular
household disinfectant containing 0.5% sodium hypochlorite should be applied.
a. Clean the patient’s clothes, bed linen, and bath and hand towels using regular laundry soap and
water or machine wash at 60–90 °C with common household detergent, and dry thoroughly.
b. Place contaminated linen into a laundry bag.

xv. Do not shake soiled laundry and avoid contaminated materials coming into contact with skin and
clothes.
xvi. Gloves and protective clothing (e.g., plastic aprons) should be used when cleaning surfaces or
handling clothing or linen soiled with body fluids.
xvii. Perform hand hygiene before and after removing gloves.
xviii. Gloves, masks and other waste generated during at-home patient care should be placed into a waste
bin with a lid in the patient’s room before being disposed of as infectious waste.
xix. Avoid other types of exposure to contaminated items from the patient’s immediate environment (e.g.,
do not share toothbrushes, cigarettes, eating utensils, dishes, drinks, towels, washcloths or bed linen).
7. REFERENCES
1. Ministry of National Health Services RCP. Guidelines Definitions, Criteria for Testing, Admission and
Management of Patients with Suspected/ Confirmed COVID-19 www.nih.org.pk2020 [updated
02-04-2020; cited 2020 08-04-2020]. Available from: https://www.nih.org.pk/wp- content/up-
loads/2020/04/20200402-Testing-Admission-Management-of-COVID-19-cases-1202.pdf.
2. Al-Tawfiq JA, Al-Homoud AH, Memish ZA. Remdesivir as a possible therapeutic option for the
COVID-19. J Travel Med Infect Dis. 2020;101615.
3. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir–ritonavir in adults hospitalized
with severe Covid-19. J New England Journal of Medicine. 2020.
4. Colson P, Rolain J-M, Lagier J-C, Brouqui P, Raoult D. Chloroquine and hydroxychloroquine as available
weapons to fight COVID-19. Int J Antimicrob Agents. 2020;105932.
5. Cortegiani A, Ingoglia G, Ippolito M, Giarratano A, Einav S. A systematic review on the efficacy and
safety of chloroquine for the treatment of COVID-19. J Crit Care. 2020.
6. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment
of COVID-19 associated pneumonia in clinical studies. J Bioscience trends. 2020.
7. Gautret P, Lagier J-C, Parola P, Meddeb L, Mailhe M, Doudier B, et al. Hydroxychloroquine and azithro-
mycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. J International
Journal of Antimicrobial Agents. 2020:105949.
8. Liu F, Xu A, Zhang Y, Xuan W, Yan T, Pan K, et al. Patients of COVID-19 may benefit from sustained
lopinavir-combined regimen and the increase of eosinophil may predict the outcome of COVID-19
progression. J International Journal of Infectious Diseases. 2020.
9. Organization WH. Clinical management of severe acute respiratory infection (SARI) when COVID-19
disease is suspected: interim guidance, 13 March 2020. World Health Organization; 2020.
10. Organization WH. Clinical management of severe acute respiratory infection when novel coronavirus (
2019-nCoV) infection is suspected: interim guidance, 28 January 2020. World Health Organization;
2020.
11. Ministry of National Health Services RCP. National Action Plan for Preparedness & Response to Corona
Virus Disease (Covid-19) Pakistan www.nih.org.pk/2020 [updated 12 February 2020; cited 2020
08-04-2020]. Available from: https://www.nih.org.pk/wp-content/uploads/2020/02/NAP-
covid-19_AL@version-3-date-12-2-2020-with-annexures.pdf.
12. UK RC. Resuscitation Council UK Statements on COVID-19 (Coronavirus), CPR and Resuscitation 2020
[Available from: https://www.resus.org.uk/media/statements/resuscitation-council-uk- state-
ments-on-covid-19-coronavirus-cpr-and-resuscitation/
13. Association AH. Coronavirus (COVID-19) Resources 2020 [Available from:
https://www.heart.org/en/coronavirus/coronavirus-covid-19-resources
 Annexure 1A: Pathway for the management of
suspected & diagnosed COVID-19 patient at
The Indus Health Network

1. Screening sites outside ER

2. Referred from other hospital
3. Unknown pnuemonia and
Collapsed patients

1. Triage assessment
2. Ask for COVID status

Sick Stable

Positive SUSPECTED Positive SUSPECTED

Proven Diagnosed Case Proven Diagnosed Case

Stabilization & Testing

Admit in Suspected
Isolation Ward Inform Local Authority Perform NPS
Assessment for Home Isolation Send to Home
Rist Stratly by ID

High Risk Low Risk Home Isolation Home Isolation Negative

Criteria Not Met Criteria Met
Positive Re-test with PCR
Inform Family
at 24 hours
Send to Home Advise home for 14 days
Re-test also Dedicated Facility Isolation Re-test if symptoms
Admit & Manage in Negetive Shift to ward OR compatible by
COVID Isolation Unit to primary referral center COVID-19 develop
 Annexure 1B: Treatment Algorithm for
hospitalized patients with severe COVID-19

Management of severe &

critical COVID cases
A. Any one of:
• R.R >24/min
Management in HDU • SpO2 <94% in air
• Confusion/drowsiness
• Send COVID specific tests
• Systolic B.P < 90mmHg
• Oxygen to maintain SpO2 > 94%
• Diastolic B.P < 60mm Hg
• Antipyretics, antibiotics as indicated
• MDI preferred over nebulization
• HCQ OR Chloroquine started
OR
• Consider IV methylprednisolone 1-2
mg/kg (5-7 days)
• Give all patients weight based
B. Patient has chest infiltrates and:
prophylactic enoxaparin unless
contra indicated • Age > 60yrs OR
• BMI > 30 OR
• DM (HBA1C > 8) OR
• Chronic Heart
• Respiratory failure Disease/HTN OR
• Hypotension • Chronic lung disease OR
If worsening • Immunosuppressed
• Severe Myocarditis
• Worsening mental status
• MODS

COVID specific tests:

CBC, CRP, Ferritin, Pro-calcitonin,
Shift to ICU
LDH, BNP, troponin, D-dimer,
Pt/APTT at baseline and 48-72
hours later
• Tociluzimab: if evidence of cytokine ECG at baseline, then 24-48hrly
storm and no contra-indications. If BNP or Troponin are high or New
• LPV/r may be considered on case to case ECG changes consult cardiology,
basis provided HIV negative OR obtain TTE
• Remdesivir may be tried if available.
• Ventilate early & management as per
ARDS protocol. Prone positioning After clinical &
beneficial. radiological
• Restrictive fluid management if not in improvement
shock.
• Close suction and HME filters.
Discharge based on
• Monitor electrolytes. Keep Mg >2 mg/dL,
discharge criteria.
K > 4 mEq/L
• If sudden and unexplained change in O2 Improving
OR new asymmetrical upper or lower
extremity edema, consider venous U/S of
affected extremity -If confirmed VTE, start
therapeutic dose anticoagulation unless
contraindicated. Patient Dies.
• If signs of nasal or digital ischemia OR Follow burial protocol
ferritin >100,000, consider Hematology
consult
Annexure 1C: Pathway of discontinuing
isolation in COVID-19 patients
 Annexure 2A: CPR of
COVID-19 Patients

Verify Scene Safety

Victim is unresponsive, activate emergency response system via mobile device (if appropriate),
and attach monitor/Defibrillator

Check for no breathing or no normal breathing (Do not listen or feel for breathing by placing
your ear and cheek close to the patient’s mouth)
• Check pulse
• Breathing and pulse check can be performed simultaneously within 5 to 10 second

No normal breathing, has pulse No normal breathing, has no pulse

Provide rescue breathing

1 breath every 5-6 second in adult
(about 10-12 breaths per minutes)
1 breath every 3-5 second in peads
(about 12-20 breaths per minutes)
using a resuscitation bag
Begin CPR Adult: 30 compression 02
breath Child and infant:
30 compression 02 breath (Single rescuer) and
15 compression 02 breath (more than 1 rescuer)

Note: Avoid mouth-to-mouth ventilation and

the use of a pocket mask. If the patient is
already receiving supplemental oxygen

Check rhythm Shock able rhythm?

Yes shockable Non shockable

Give 1 Resume CPR immediately

for about 2 minutes
and check rhythm

Further management according to adult and peads AHA 2015 guideline

 Annexure 2B: High quality CPR
Components-COVID 19

HIGH QUALITY CPR COMPONENTS

COMPONENT ADULT CHILD INFANT

Compression ventilation 1 or 2 rescuers 1 or 2 rescuers 30:2 1 or 2 rescuers

ratio without advanced 30:2 2 or more rescuers 15:2 30:2
airway 2 or more rescuers 15:2

Compression ventilation Continue compression at a rate of 100-120/min Give 1 breath every 6 second (10
ratio with advanced airway breath per minute)

Compression rate 100-120/min

Compression depth At least 5 cm About 5 cm About 4 cm

Hand placement 2 hands on the lower half
breastbone (Sternum)
2 hand or 1 hand (optional
for very small child) on the
lower half breastbone
(sternum)
1 rescuer: 2 fingers, just
below the nipple line
2 rescuers: 2 thumb
encircling just below the
nipple line

Chest Recoil Allow full recoil of chest after each compression

Minimizing Interruption Limit interruption in chest compression to less than 10 second

Annexure 3: instructions for home management
of COVID-19 suspects

indushospital indus_hospital theindushospital the-indus-hospital The Indus Hospital

Used with permission from Aga Khan University