CMC Handbook For Management of COVID19

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CHRISTIAN MEDICAL COLLEGE

VELLORE
HANDBOOK
FOR
THE CLINICAL MANAGEMENT OF
COVID19
2020
CMC-Handbook for Clinical Management of COVID19

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An exhortation
"You will not only be curing diseases, but will also be

battling with epidemics, plagues and pestilences and
preventing them. ……………
The practice of medicine affords scope for the exercise of the

best faculties of mind and heart. You must learn to be cool,
collected and quiet; to have presence of mind; rapid thought
and action in the most trying circumstances. You must learn to
have wise judgement in moments of great peril; you must train
your tempers until you have complete control, for your temper
will often be taxed by exasperating patients and their friends.
You must learn never to betray indecision and worry, for if you
become flustered and flurried, you will lose the confidence of
your patients. Practice and experience will train you to have
firmness and courage. Do not always look for gratitude, for
sometimes when you are most deserving, you will get the least.
Do not expect too much of your patients, do not betray surprise
or be aggravated if you find they are taking medicine from half
a dozen doctors. There will be disappointments; your pet theory
will be dashed to the ground; your most painstaking laborious
work, unsuccessful; there will be cares, anxieties, failures
which are very common to the professional life.
There are the valleys into which you descend, but stand up
bravely, be true and keep on climbing. Face trials with a
smile, with head erect and calm exterior. If you are fighting
for the right and for a true principle, be calm and sure and
keep on until you win!”
An excerpt from Aunt Ida’s speech at the first graduation in 1922

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TABLE OF CONTENTS
No Content Page
1 Infection prevention and control in COVID areas
Transmission risk to healthcare workers 05
Appropriate use and re-use of PPE 07
2 Administration, checklists and templates
Job descriptions 09
Work routine in COVID wards 11
Patient transfer checklist 14
History sheet template 15
Daily progress notes and handover template 19
How to obtain a nasopharyngeal specimen 21
Discharge checklist 22
Death care checklist 23
3 Medical Management
Initial evaluation and diagnosis of a SARI case 25
Treatment protocol 28
Principles of Monitoring 31
Respiratory failure and oxygen delivery devices 33
Fluid Management and nutrition 40
Management of common comorbidities
Diabetes 43
Renal dysfunction 45
Hypertension 46
COPD/Asthma 47
Criteria for transfer to Kannigapuram Campus 51
Discharge criteria 52
Non-escalation/de-escalation of care 53
CPR protocol 54
4 Communication, compassion and ethical care 56
5 Financial aspects of patient management 60
6 Appendices
Palliative Care in COVID19 68
NIV and intubation in COVID19 74
7 Information sheets
Admission (English) 80
Admission (Tamil) 84
Discharge (English) 88
Discharge (Tamil) 90
Bereavement (English) 93
Bereavement (Tamil) 95

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INFECTION PREVENTION AND CONTROL

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TRANSMISSION RISK TO HEALTH CARE WORKERS IN THE CONTEXT OF

COVID-19 AND HOW TO MINIMISE IT
(Priscilla Rupali)
Health care workers in any capacity are at high risk of getting infected with COVID-19 infection but
they can also serve as amplifiers of an outbreak in health care facilities if they are ill. This guidance
is intended to protect our HCWs and patients from nosocomial transmission of COVID-19 infection.
PROCEDURES WITH HIGH RISK OF TRANSMISSION include:
1. Close contact with a person with COVID-19 in the community without PPE
2. Providing care to a patient infected with COVID-19 without PPE or hand hygiene (physical
exam, nursing care, performing aerosol generating procedures like swabbing, giving
nebulisations, NIV, NG tube insertion, suction for a patient on tracheostomy or endotracheal
tube; specimen collection, radiologic testing, contact with infected secretions or the patient’s
environment)
3. Lab exposure to respiratory specimens from infected patients
WHAT IS THE CURRENT EVIDENCE?
1. Nosocomial transmission from patients to staff is very low in reported literature.

2. Current personal protective equipment and protocols if meticulously followed are sufficient
to prevent transmission in a health care setting.
3. There is rampant community transmission and hence remember to protect yourself both
inside and outside the health care facility.
PRECAUTIONS TO BE FOLLOWED TO MINIMIZE RISK OF INFECTION
While inside COVID treatment areas
1. Bring only what is absolutely necessary to work.

2. Use the prescribed PPE appropriately for the procedure and exposure anticipated. This
is your last line of defense against infection and prevents transmission to patients, colleagues
and family. Even the best PPE is ineffective if not used properly.
3. Follow correct donning and doffing protocols per the posters in the donning/doffing
room. Ensure a buddy system is followed (someone observes you don and doff) to ensure no
breach of infection, prevention and control practices
4. Ensure the N-95 fits snugly. Shave off any facial hair along the fit-line.
5. Follow rigorous hand hygiene before and after patient care activities
6. While examining patients in their rooms, follow the rule “Minimum number of people,
minimum time, minimum contact”. Close contact = < 1 m distance from the patient for > 15
minutes.
7. Minimize repeated donning and doffing (i.e., taking too many breaks for coffee, meals and
visiting the rest room)
8. Dispose PPE appropriately after use.

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While moving elsewhere in the hospital
1. Do not carry your N95 mask outside the COVID treatment area, instead store it in the
designated area in a brown bag labelled with your name and employment number, and switch
to a surgical mask. Use a visor with the surgical mask for all patient care interactions
outside COVID areas that do not involve high risk procedures.
2. Maintain physical distancing even when among colleagues and friends.
3. Follow cough etiquette.
4. Follow rigorous hand hygiene before and after patient care activities
When going home
1. Switch from the N95/surgical mask, to a cloth mask. Store or dispose the former per protocol.
2. Disinfect any gadgets or instruments you will be taking home.
3. Avoid close contact with any family members till you have washed your hands and changed
out of your work clothes/taken a bath
4. Self-monitor for temperature and respiratory symptoms daily (see guideline below)
While in the Community
1. Wear a cloth mask at all times, and avoid touching the front of the mask.
2. Maintain physical distancing at all times, hence avoid large gatherings.
3. Follow cough etiquette.
4. Minimize touching common-use surfaces. If unavoidable, use the non-dominant hand.
If you develop fever +/- sore throat/cough/diarrhoea/breathlessness/loss of smell or taste
1. Inform your supervisor and do not come to the workplace.

2. Inform SSHS telephonically and report to Fever Clinic
References
1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/public-health-management-
hcw-exposed.html
2. Hunter E, Price DA, Murphy E etal. First screening of health care workers in England. The
Lancet Volume 395, Issue 10234, 2–8 May 2020, Pages e77-e78.
3.https://www.mohfw.gov.in/pdf/AdvisoryformanagingHealthcareworkersworkinginCOVIDandNo
nCOVIDareasofthehospital.pdf
4. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/health-
workers

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APPROPRIATE USE AND RE-USE OF PPE

(Malathi Murugesan)
What PPE is recommended
Area Procedure PPE Re-use policy for N95

COVID All patient care Eye protection: goggles/face Hand over mask to the
confirmed wards activities, for shield/visor mask counter in C ward
and ICUs the entire shift Respiratory protection: N 95 mask in a brown paper bag
Body protection: apron, fluid resistant labelled with your name
gown, gloves, shoe covers, and Emp No. at the end
cap/headcover. Hazmat suits are also of the shift
available.
COVID suspect All patient care Eye protection: goggles/face Mask A – Day 1, 4, 7
wards and ICUs activities, for shield/visor Mask B – Day 2, 5, 8
the entire shift Respiratory protection: N 95 mask Mask C – Day 3, 6, 9
Body protection: apron, fluid resistant Hand over mask to the
gown, gloves, shoe covers, cap mask counter in C ward
in a brown paper bag
labelled with your name
and Emp No. at the end
of the shift
*This policy is subject to revision from time to time. Please follow the latest guidelines available under
COVID information and Guidance -> Infection Prevention Control Guidelines on the Intranet
(http://172.16.11.221/misc/corona/HICC.html).
How PPE should be donned and doffed
Please click the “COVID19 Information and Guidance” link on the Intranet
(http://172.16.11.221/misc/corona/HICC.html), followed by the subheading “Training Materials” to view
videos on donning and doffing of full PPE. Additionally all wards and ICUs have posters in the donning
and doffing rooms.

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ADMINISTRATION, CHECKLISTS, TEMPLATES

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JOB DESCRIPTIONS OF TEAM MEMBERS

(Ronald Benton Carey)
1. Senior consultant
The senior consultant cover will be for a week and will operate from the Covid Command
Centre. They are drawn from Medicine and allied specialties. The pager number is 05966.
Responsibilities of the senior consultant include
- Troubleshooting the junior consultants on the floor

- Providing expert advice for difficult clinical decisions
- Being the signatory for the required Government forms
- Overseeing Level 1 admissions done through the Covid Command Centre
2. SARI consultant
The SARI consultant covering the wards with COVID suspected patients will be responsible
for all admissions into the suspect wards and the Level 2 wards (currently E ward – but this
list may be expanded as the numbers go up). They will carry the bleep 05640 and will oversee
management of all suspect cases, organise swabbing, and transfer of these patients to the
appropriate wards when the results are ready.
3. COVID ward consultants

The wards are divided between a set of consultants drawn from various medical specialties.
The consultants will do rounds on the allocated ward and be available for help until 8 pm.
After 8 pm, the night cover will be provided by the ward consultants on rotation. Night cover
bleep is 05941.
4. Level 1 admissions consultant

The Level 1 admissions consultant at the COVID Command Centre will be responsible for all
admissions of patients with asymptomatic and mild disease. The team communicating the
results of the PCR test to the patients, the patient help desk and the emergency medicine
department team will contact the Level 1 admissions team to get a bed for the patients. The
Level 1 admissions consultant will get information about the bed status through the Medical
records technician in the CCC. Level 1 admissions consultant will be available on 6333/05599
5. Kannigapuram consultant
The Kannigapuram consultant will be responsible for all admissions to Kanigapuram COVID
wards. They will regulate admissions both from CMC town campus and from Ranipet DDHS.
The bleep number is 05924 and ward number is 5517.

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6. Registrars and interns
The registrars and interns on the floor are drawn from various specialties. Each person will
do a 6-hour shift for a period of 7 days. At present there are 4 shifts: 8 AM to 2 PM. 2 PM to
8 PM, 8 PM to 2 AM and 2 AM to 8 AM. (Kindly note the work day starts at 8 am and finishes
the next day 8 am. Therefore the 2 am-8 am shift will be counted as part of the previous day
schedule.)
The responsibilities include

- Working up the patient
- Monitoring the vital signs and being vigilant about clinical deterioration
- Sending investigations if required
- Writing medication orders
- Attending to emergencies
- Writing discharge summaries
- Organising transfer to a higher level of care if the patient deteriorates.
- Discussing cases with the consultant

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WORK ROUTINE IN COVID WARDS

S.No Activity Who Remarks

Work up new Registrar/Intern  Take essential history
admissions  Do the most essential physical examination
 Pay attention to vital signs – Calculate NEWS2
1.
score at admission
 Document in the Discharge summary under the
respective admission unit
Monitor Nurse  Clinical + NEWS2 score
/Registrar/Intern  NEWS2 score at the beginning of every shift
2.
should be noted by the ward team and escalation
should be considered if the score is going up.
Rounds Consultant/Registra The consultant does a quick review with the team of
all the patients in the ward before the rounds.
3. r/ Intern
Prolonged discussions should be avoided. No more
than 2 people should do the rounds.
Inform results, progress and possible discharge date.
4. Talk to the Lead consultant
patient during the rounds
The afternoon shift registrar should inform the
Talking to Afternoon shift
relatives telephonically about the condition of
5. relatives over registrar
relatives who are unable to speak to their relatives for
phone
various reasons.
Progress notes Registrar/Intern  It should be done in the IP handover section of
clinical workstation under the SARI login.
 A very concise note of the decisions made in the
6. rounds should be made by the morning shift team.
 Any communications done by the afternoon shift
to the relatives should also be mentioned in the IP
handover section.
Any decision about non-escalation and shifting patient
Update non- Registrars
to ICU should be communicated to the concerned unit
7. escalation and
by the registrar on the floor.
ICU shifting
decisions
Handover Registrars  A detailed handover of the patients who are ill and
between shifts are on oxygen should be done.
8.
 A very concise handover of the stable patients
should be done.
A team of volunteers will update the patients and the
Updating Finance help desk
relatives about the finances and the payment methods.
9. patients and
relatives about
finances and the

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Frequently asked questions regarding patient care
1. Which units are the patients  Patients are admitted under the medical unit that
admitted under? worked up the patient in Emergency Department.
 Patients transferred from the wards into the SARI
wards remain under the same treating unit, unless taken
over specifically through consultation by another unit.
 Old CMC patients remain under their parent medical
unit and new patients will be admitted under the
admitting medical unit for the day.
 Patients from the Triage clinic will be admitted under
the admitting medical unit for the day.
Routine blood investigations many be done by leaving

2. How do I get blood investigations
lab orders for phlebotomists who come to draw blood
done?
at 10 am every day. Urgent blood investigations should
be done by the doctors posted in the ward.
An investigation should not be ordered unless it is

going to change the management of the patient.
You may leave your name and employment number in

3. How do I get SARI and individual
the Whatsapp group for doctors posted in COVID
medical units clinical workstation
wards. Alternatively, you could call 2921 (Mrs. Uma)
login?
or 2031 (Mrs. Roselin) and request for access.
If a patient becomes critically ill and a clinical decision
4. What is the process for shifting the
is made either to shift to ICU or to provide only
patient to ICU or making a
palliative/supportive care (non-escalation), the
decision on non-escalation?
decision should be ratified by the senior consultants of
the medical unit concerned. The registrar looking after
the patient should call the unit concerned and discuss.

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Frequently asked questions on the movement and safety of healthcare workers
1. How
, Go to C ward (for E, I, Isolation and ICUs) via the stairs behind ED
to enter and leave
or N1 ward terrace via the stairs near OR. Change into scrubs, keep
the COVID wards?
valuables in the locker provided, collect the N95 mask and go to
your ward. Every ward has a donning and doffing area. Don PPE
and enter the ward. At the end of the shift, doff PPE in the doffing
area of your ward, go to C ward, collect your street clothes, shower,
leave your scrubs for disinfection, change to street clothes and
leave.
No. Doffing has a high risk of infection and so doffing has to be
2. Can I partially doff
complete and you should leave the ward once doffed.
midway through the
shift?
HCQ is available for those who wish to take it. Kindly go through
3. Should I take HCQ
the guidelines put up by HICC available in the intranet.
prophylaxis?
(http://172.16.11.221/misc/corona/HICC1PFSS.html)
The HICC does not recommend quarantine for healthcare workers
4. Can I get back to regular
after working in COVID wards. This is based on the CDC guidelines
work after a posting in a
on the premise that with the use of appropriate PPE the chance of
COVID area?
infection is negligible.
There will be a certain amount of stress while working on the SARI
10. How can I prevent being
ward – you will be doing things you are not familiar with, and may
stressed out?
be worried about the risk of infection. These are normal responses to
the working situation which everyone will go through. We also need
to watch for and keep an eye on each other’s needs both during and
after the COVID postings. Don’t be anxious to voice any such
thoughts that may be going through your mind.
For any help please talk to your consultant on the floor. Don’t
11. How can I get help?
hesitate to contact the senior consultant if required. You may also
contact your own department supervisors.
We are all working together from different departments and units in
12. How can I improve team
a stressful environment. We need to take time to get to know, help,
building?
support and learn from each other. There will be the normal give and
take of working together. Keep up the team spirit in order to provide
good care and ensure a safe environment. All your suggestions for
individual patient care and running of the SARI service are welcome
and may be conveyed to the consultant on the floor or the senior
consultant or through your own department seniors.

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PATIENT TRANSFER CHECKLIST

(Malathi Murugesan)
General principle: Avoid movement of patients unless medically necessary e.g. portable X-rays
are preferred to X rays done in Radiology department
TRANSFER WITHIN HOSPITAL
S.
Step Responsibility Additional details
No
Inform Central Command
Centre (8800) about patient Follow the protocol for
1. Nurse
name, time of transfer, ‘from’ ‘Movement of patients and staff’
and ‘to’ locations under the Infection Prevention
Coordinate with SARI ward and Control section of the
floor manager (05982), house- COVID19 information and
keeping supervisor (05232) guidelines on the Intranet
2. and security officer (05294) to CCC (http://172.16.11.221/misc/corona/HICC1IP
coordinate transfer, block lifts CG.html)
and arrange terminal
disinfection
Put a surgical mask on the
3. Nurse
patient
Eye protection: goggles/face
shield/visor
Only one HCW and attender to Respiratory protection: N 95
4. accompany the patient in the HCW and attender mask
lift wearing appropriate PPE. Body protection: apron, fluid
resistant gown, gloves, shoe
covers, cap
Follow the designated route to
reach the destination to Mentioned in the ‘Movement of
5. HCW and attender
minimize exposure to other patients and staff’ protocol
staff, patients and visitors
TRANSFER HOME
If a patient is eligible for discharge (see section on ‘Discharge criteria’), staff nurse to call 2040/05246
and inform ‘transportation of discharged patient’ with details. Transport booking will be initiated,
attender to transport patient along the designated route wearing full PPE to reach destination, patient
will be sent home in an ambulance (108/private).

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HISTORY AND EXAMINATION TEMPLATE

Basic principles:
1. Level 2 patients admitted through ED will be worked up by the SARI side Medicine
registrars; they do not need to be worked up again. However, if required, more history
may be collected and physical examination findings confirmed.
2. Level 1 patients need a concise history and physical examination. Prolonged contact
with the patient is not advisable.
3. The following template may be used while for collecting history and documenting physical
examination findings.
TEMPLATE
(Refer to the section ‘Initial evaluation of a SARI case’and the ‘Treatment protocol’for a detailed
description of all sections marked*)
Fever: Yes No Duration: _____days Chills: Yes No
Sore throat: Yes No Duration: _____days
Cough: Yes No Duration: _____days Sputum: No Yes Colour: __________
Rhinorrhea: Yes No Duration: _____days
Breathlessness: Yes No Duration: _____days
Diarrhoea: Yes No Duration: _____days
Episodes per day:______
Watery Bloody
Vomiting: Yes No Duration: _____days
Episodes per day:______
Anosmia: Yes No Duration: _____days
Ageusia: Yes No Duration: _____days
Malaise Yes No
Myalgia Yes No
Any travel in the last 2 weeks: Yes No If yes, where? ___________________________
Contact with a COVID confirmed/suspect individual: Yes No
Comorbidities:
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Hypertension Yes No Diabetes Yes No
Chronic lung disease Yes No Cardiac failure Yes No
Malignancy Yes No PTCA/CABG Yes No
On immunosuppressive medication Yes No
*Risk factors for severe disease: Yes/No
Current medications:
1.
2.
3.
4.
Smoking Never smoked Current smoker Ex-smoker Stopped yrs ago
Cigarettes per day: No. of years of smoking: Pack years:
Alcohol consumption: Never Current drinker Ex-drinker No of years of abstinence:
Type of alcohol consumed: ____________________
Amount consumed on a typical drinking day:
Frequency of drinking in a month 1-2 3-4 5-6 7-9 10+
Allergies/Intolerances
Name of drug Nature of reaction
Examination
RR: SpO2: FiO2: Weight BMI:
HR: BP: Temp: Height:
Orientation: Time Place Person
GCS: Eyes /4 Verbal /5 Motor /6 Total /15
NEWS2 Score:

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Pallor + - Icterus + - Cyanosis + - Clubbing + - Lymphadenopathy + -

Pedal oedema + -
Other relevant general exam findings
CVS Abdomen
RS CNS
Clinical differential diagnoses for the presenting
1.
2.
3.
Other coexisting problems
1.
2.
3.
4.
5.
*Severity Category: Asymptomatic/Mild/moderate/severe/critical
*Investigations: Refer clinical workstation
*Management: Please see the Management subsection of the chapter on ‘Initial evaluation of a
SARI case’ for the various components of the management plan to be documented and followed
Management plan Task completed

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1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
5. ___________________________________________________________________________
6. ___________________________________________________________________________
7. ___________________________________________________________________________

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DAILY PROGESS NOTES AND HANDOVER TEMPLATE

PROGRESS NOTES
Where to document: CWS IP handover section (right click on patient’s name on the IP list)
What to document:
A. Asymptomatic patients:
1. Any symptoms?
2. Latest set of vital signs and NEWS2 score
3. Respiratory findings if examined
4. Plan made
B. Symptomatic patients
1. Improvement or worsening of symptoms
2. Latest set of vital signs and NEWS2 score
3. Relevant physical examination findings
4. Plan made

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DOCTORS HANDOVER SHEET

DATE: TIME: HANDED OVER BY:
WARD: HANDED OVER TO:
Patient Ward Problems RR SpO2 Temp BP Pulse Conscious- Pending

name, and bed rate ness worklist
Hospital number
no.

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HOW TO OBTAIN A NASOPHARYGEAL SPECIMEN

(Abi Manesh)
1. Explain the procedure to the patient and obtain their consent

2. Order Qualitative SARS COV2 RT-PCR test online (Code:07107)
3. Fill the ICMR form (online) and HICC form, collect the viral transport medium (VTM)
container and label it with the patient’s name and hospital number
4. Perform hand hygiene
5. Wear full PPE: Cap, goggles/ eye wear, N95 mask, Visor, surgical gown/ apron (fluid
repellent), nitrile gloves, shoe covers
6. Ask the patient to take off their mask and blow their nose into a tissue to clear excess
secretions from the nasal passage
7. Remove the swab from the packaging
8. Tilt the patient’s head back slightly to make the nasal passage more accessible
9. Ask the patient to close their eyes to lessen the discomfort
10. Gently insert the swab along the nasal septum, just above the floor of the cavity, to the
nasopharynx, until resistance is felt (this would roughly be equal to the distance between the
nostrils and the outer opening of the ear). If you detect resistance to the passage of the swab,
withdraw it and reinsert at a different angle, closer to the floor.
11. Leave the swab in for a few seconds to absorb secretions, then rotate the swab in place several
times before withdrawing it. (Single swab, single nostril)
12. Ask the patient to reapply their mask.
13. Open the collection tube and insert the swab into the tube. Break the swab at the groove and
discard what remains of the swab.
14. Hand over to an attender who is wearing appropriate PPE, for transport to Virology
15. Doff PPE per protocol
16. Perform hand hygiene (See Reference1 for a detailed video on the procedure).
Figure: Blue lines indicate the direction in which the swab should be advanced
Reference:
1. Marty FM, Chen K, Verrill KA. How to Obtain a Nasopharyngeal Swab Specimen. N Engl J
Med. 2020;382(22):e76. doi:10.1056/NEJMvcm2010260, available at
https://www.nejm.org/doi/full/10.1056/NEJMvcm2010260

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DISCHARGE CHECKLIST
Note: Please follow discharge criteria as given in the COVID-19 information and guidance link
on the Intranet, which is subject to change
1. This checklist is to be administered by the doctor before handing over the discharge
summary to the patient
2. The patient is to be discharged only after all of the below are done.
1 Duration of home quarantine explained Yes No
2 Advice to wear mask given Yes No
3 Advice to be in a single room with good ventilation given and use Yes No
separate bathroom if possible
4 Advice to avoid close contacts with others explained Yes No
5 Need for hand hygiene explained Yes No
6 Advice to strictly stay indoors given Yes No
7 Warning signs explained to patient and relatives (breathlessness, Yes No

pain/pressure in the chest, bluish discolouration of extremities,
confusion)
8 Surgical mask given Yes No
9 All medications given for 1 month Yes No
10 Copy of the Discharge patient information sheet given (see section Yes No
on Patient information sheets)
11 Initiate ‘Patient transfer checklist – transfer home’ to shift the Yes No

patient

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DEATH CARE CHECKLIST FOR COVID SUSPECT/COVID CONFIRMED

(Malathi Murugesan)
S.No Task Responsibility PPE/other details

If COVID suspect and not yet
Full PPE suit (gloves, N95 mask,
swabbed, get relatives’ consent for Clinician in
1. goggles, water resistant gown, shoe
nasal swab and send for testing charge
covers) while obtaining sample
immediately
Explain the procedures and death
protocol to the relatives. Use the “Bereavement advice”
Ascertain whether they wish to Clinician in information sheet in the appendix to
2.
cremate or bury the body, and charge cover relevant points during
where they intend to do so (in communication
Vellore/outside Vellore)
Prepare the body as per death care
checklist in the mortuary protocol
(COVID information and guidance Full PPE suit (gloves, N95 mask,
3. - > Infection Prevention and Staff nurse goggles, water resistant gown, shoe
Control guidelines - > mortuary covers)
protocol)
http://172.16.11.221/misc/corona/HICC1IPCG.html
Inform HICC (2013/05090) about

the patient’s death, COVID status
(confirmed/suspect), relatives’
Clinician in
4. wishes regarding cremation/burial N.A
charge
and where they wish the interment
to take place (inside/outside
Vellore)
Inform Central Command Centre
5. Staff nurse N.A
(8800) prior to transfer
Transfer protocol – block the lift
6. and coordinate environmental CCC N.A
disinfection
Transfer the body to the mortuary Staff nurse
7. Full PPE suit
via designated lift and attender
Fill death audit forms (fever death
preliminary investigative report and
fever death detailed investigative Death Audit Forms are available
report) within 24 hours, to be signed Clinician in under the COVID19 Information and
8. guidance intranet link under the
by the Senior consultant, and send a Charge
scanned copy to HICC by email section ‘Forms’
(http://172.16.11.221/misc/corona/HICC2FORMS.html)
(covid19hicc@cmcvellore.ac.in)
for forwarding to the DDHS

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MEDICAL MANAGEMENT

25
INITIAL EVALUATION OF A SEVERE ACUTE RESPIRATORY ILLNESS (SARI)

CASE: SYNDROMIC APPROACH
(OC Abraham)
1. Suspect COVID-19 in any patient with acute onset (<14 days) of the following symptoms:
a. Fever
b. Cough
c. Breathlessness
d. Runny nose
e. Sore throat
f. Diarrhoea
g. Loss of smell or taste
h. Myalgia
i. Fatigue
j. Drowsiness, confusion, disorientation
2. Always consider other causes of acute febrile illness (dengue, malaria, scrub typhus, typhoid
fever etc.) as differential diagnosis. Sometimes they may co-exist especially in AFIs with a
respiratory syndrome
3. SARS-COV-2 PCR testing for all suspect cases
4. Immediate implementation of appropriate IPC measures (MoHFW Guidelines)
5. Assessment of risk factors for severe disease

a. Age >60 years
b. Presence of any significant comorbidities
i. Coronary artery disease (MI, PCI or CABG within previous 6 months)
ii. CVA within last 6 months
iii. Heart failure (NYHA Class 3 and 4)
iv. COPD (mMRCDyspnea Scale Grade 2, 3 and 4)
v. Poorly controlled bronchial asthma (daily use of salbutamol inhaler for symptoms,
nocturnal symptoms, ED/hospital visit for exacerbation within 1 month)
vi. Uncontrolled Diabetes Mellitus (HbA1C ≥9% or random glucose >300 mg/dl)
vii. Systemic hypertension with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg
viii. Active cancer (therapy ongoing or within last 6 months)
ix. Chronic kidney disease (based on history)
x. Decompensated chronic liver disease (Presence of edema, jaundice, ascites,
encephalopathy)
xi. Transplantation (SOT or HSCT)
xii. On immunosuppressive treatment currently
xiii. Morbid obesity (BMI >40)
6. Decide whether resuscitation is required for this patient:

Severity scores, ABG, CXR, ECG are helpful

26
7. Decide whether resuscitation has been agreed upon for this patient
Confirm with lead consultant, see section on escalation/de-escalation
8. If indicated and agreed upon, initiate resuscitative measures

A- Airway: assess need for intubation
B- Breathing: Assess need for oxygen therapy
C- Circulation: IV access, IV fluids/inotropes/vasopressors
D- Neurological Disability: Support A, B, C and check glucose and electrolytes
9. Assess need for critical care intervention – any one of the following:
i. Respiratory distress with difficult airway
ii. RR>30, Unable to speak full sentences
iii. Cyanosis or SpO2<85% on room air; ABG P/F ratio <250
iv. Systolic blood pressure <90 despite fluid resuscitation
v. Agitated, confused, (or comatose) with respiratory distress
vi. Early MODS: 2 or more organ failures
vii. CURB 65 (confusion, urea >40, RR>24, BP<90 and Age >65) score of 3 or more
viii. Q SOFA score– 2 or more of HAT (Hypotension, Altered mentation, Tachypnoea)
10. Assess disease severity and need for admission*
Severity Definition Admission

Asymptomatic Close contact with COVID19 positive, no
Admit
contact symptoms
Mild Any COVID19 related symptoms without
Admit
symptomatic pneumonia or hypoxia and resp rate < 24/min
Pneumonia (clinical or radiological) or
Moderate hypoxia and resp rate ≤ 30/min, and SpO2 ≥ Admit
90% on room air and no respiratory distress
Pneumonia and ≥1 of: resp rate > 30/min,
Severe severe respiratory distress, SpO2 < 90% on Yes, consider ICU
room air
Critical ARDS or sepsis ± shock Yes, ICU
*Admission criteria are subject to change from time to time. Please follow the updated protocol
11. Investigations (in admitted patients)

i. CBC
ii. CRP
iii. Blood glucose
iv. LFT
v. Blood urea, serum creatinine
vi. Electrolytes
vii. ABG
viii. Blood culture x 2(severe and critical category)
ix. Sputum gram stain and C/S(severe and critical category)
x. Nasopharyngeal swab for Qualitative PCR for SARS-COV2
xi. Portable CXR
xii. ECG

27
xiii. D-dimer
xiv. Ferritin
xv. CPK
xvi. PT, aPTT (prior to anticoagulation)
12. Management
a. Drug treatment
i. Symptomatic treatment
1. Paracetamol for fever
2. Cough suppressants
ii. VTE prophylaxis*
iii. Dexamethasone* for patients on oxygen
iv. Remdesivir* for patients on oxygen
v. IV fluids/nutrition (see section on ‘Fluid management and nutrition’)
vi. Management of co-morbidities
b. Supplemental oxygen therapy: If emergency signs and /or SpO2 <96%, based on
clinical judgment. (See section on ‘Respiratory failure and oxygen delivery devices’ for
details). If there are significant oxygen requirements*, to consider awake proning. In
case of increasing requirement of oxygen (> 5 L/min) consider shifting to intensive care
unit for non-invasive or invasive ventilation.
c. Advance care planning for all hospitalized patients; discuss with patient, family
d. Monitoring plan*: Vital signs, SpO2, level of consciousness, physical exam, NEWS2
score#, relevant investigations like D-dimer based on the ‘Treatment protocol’. Please
follow the format given in the “Daily progress notes and handover” section to
document daily clinical findings and the guidance given in the “Monitoring” section for
the monitoring required.
e. Communication: With the patient and relative regarding investigations, results,
progress
*See next section on “Treatment Protocol”
#
Use the NEWS2 score to determine the frequency and intensity of monitoring required and to
identify patients who are deteriorating. See section on “Principles of monitoring COVID19
patients’.

28
TREATMENT PROTOCOL
(COVID Clinical Group, CMC Vellore)
Note: Treatment guidelines are updated from time to time. Please consult the latest guidelines available
under the COVID19 Information and Guidance link of the Intranet, Subsection – “Protocols for Patients”
(http://172.16.11.221/misc/corona/HICC1PFP.html)

29

30
Remdesivir additional information:
Renal impairment: eGFR ≥30 mL/minute: No dosage adjustment necessary; eGFR <30
mL/minute: Avoid use; formulation contains the excipient cyclodextrin
Hepatic impairment: No data available
Common side effects:

1. Transaminase elevation (do not initiate remdesivir in patients with ALT ≥5 times normal)
2. Infusion reactions: diaphoresis, hypotension, nausea, shivering, and vomiting.
Interactions:
1. Co-administration with HCQ or chloroquine should be avoided
2. Co-administration with dexamethasone may reduce remdesivir levels but this is not believed
to be clinically significant.
3. Avoid using with phenytoin, carbamezepine, efavirenz and nevirapine.

31
PRINCIPLES OF MONITORING COVID-19 INFECTED PATIENTS

1. The key factor in monitoring patients is listening to the complaints, making a clinical
assessment and serial monitoring of the NEWS2 score using vital signs.
2. NEWS2 (National Early Warning System v.2) is warning score that standardizes the
assessment and response to acute illness. It is based on a simple aggregate scoring system
for seven physiological parameters (respiratory rate, SpO2, systolic blood pressure, pulse
rate, level of consciousness or new confusion, temperature, inspired oxygen). Access at
https://www.mdcalc.com/national-early-warning-score-news-2
3. The frequency of monitoring of vital signs should be based on the NEWS2 score.
4. Escalation to Level 2 care should be based on a combination of clinical assessment and

the NEWS2 score.
5. NEWS2 score may be calculated using calculators available online and serially marked
on the NEWS2 chart.
Note: SpO2 Scale 2 is to be followed for patients with hypercapneic respiratory failure

32
Clinical response to NEWS2 score
NEWS2 score Response

0 Monitor Vital Signs every 12 hours; No action needed;
Patient to remain in Level 1
1 – 4 (Low score) Monitor q6h.
Based on clinical assessment, discuss with consultant about
shifting to Level 2 ward
5 or more Monitor 1 hourly.
Shift to Level 2 ward immediately.
Consider sepsis.
7 or more Shift immediately to Level 2 ward,
Consider shifting to ICU based on clinical assessment

33
RESPIRATORY FAILURE AND OXYGEN DELIVERY DEVICES

(Binila Chacko and Kartik G)
Does the patient have respiratory Types of respiratory failure

failure? •Type 1 - Alveolar disease
• Represents the failure of the lung to Hypoxemic Respiratory failure
maintain adequate gas exchange •Type 2 - Alveolar hypoventilation
• Characterized by ABG abnormalities Hypercapneic Respiratory failure
• PaO2 < 60 mmHg with or without •Type 3 - Post operative atelectasis
Hypoxemic Respiratory failure
hypercarbia PaCO2 > 46 mmHg
•Type 4 - Shock related hypoperfusion
(with drop in pH<7.30) Hypercapneic Respiratory failure
ARDS
• Evidence of bilateral infiltrates on the
chest radiograph (not explained by fluid
overload or pulmonary edema)
• P/F ratio <300 on a PEEP >5cm water
• Mild ARDS: 200 to 300
• Moderate ARDS: 100 TO 200
• Severe ARDS: <100
Glossary of important terms:
ABG = Arterial blood gas analysis, a diagnostic tool to measure the partial pressures of gas in blood
and the acid-base balance
PaO2 = Partial pressure of oxygen in arterial blood, a measure of how well oxygen is able to move
from the lungs into the blood. Reported in the ABG.
PaCO2 = Partial pressure of carbon dioxide in arterial blood, a measure of ventilation (the rate and
depth of breathing). Reported in the ABG.
pH = measured acid-base balance in the blood. Reported in the ABG.
ARDS = Acute respiratory distress syndrome
P/F ratio = arterial pO2 (“P”) from the ABG divided by the FiO2 (“F”) – the fraction (percent) of
inspired oxygen that the patient is receiving expressed as a decimal (40% oxygen = FiO2 of 0.40).
Normal range 300-500.
PEEP = positive end expiratory pressure, the pressure in the lungs above atmospheric pressure that
exists at the end of expiration in the mechanically ventilated patient
Alveolar arterial gradient (A-a gradient): It is a marker of diffusion of oxygen from the alveolus
to the pulmonary capillary. If increased, it generally indicates a problem in the lung. Normal range
5 to 15 mmHg (can be obtained from the ABG result).
SpO2 = Fraction (%) of oxygen saturated haemoglobin relative to total haemoglobin in the blood.
Obtained from pulse oximetry. Normal > 95%

34
WHAT IS CAUSING THE RESPIRATORY FAILURE? BROAD OVERVIEW
What's causing the respiratory failure?
Arterial blood gas
Hypoxemia
Normal or decreased CO2 Increased CO2 with respiratoy acidosis#
Airway related causes Alveolar arterial gradient
Alveolar or interstitial
Normal Increased
disease
Hypoventilation
Hypoventilation
plus
Pleural disease unrelated to lung
airway/alveolar/ple
pathology
ural disease
# The PaCO2 must always be considered in relation to the pH!! A drop in in pH to <7.30 / dropping
trend of pH in patients would be diagnostic of an acute process.

35
TYPES OF OXYGEN DELIVERY DEVICES

Oxygen delivery devices are classified based on flow (low flow or high flow), performance (variable
or fixed) and whether they are non-rebreathing or rebreathing systems.
Low flow devices are so called as they deliver oxygen at less than the peak inspiratory flow rate
(PIFR). Examples include nasal cannula, simple face mask and partial re-breather masks. High flow
devices deliver oxygen at flow rates higher than the PIFR. These systems have adequate reservoir
capacity that enables the delivery of adequate flow.
In a variable performance device, the oxygen concentration of the air-oxygen mix reaching the
alveoli is not constant; the final O2 concentration dependent on the oxygen flow rate, size of the
reservoir and the respiratory rate of the patient. A fixed performance device on the other hand is not
influenced by these factors and is able to provide a fixed inspired oxygen concentration irrespective
of the patient’s respiratory rate (e.g. a venturi device).
Re-breathing systems allow some mixture of exhaled gases while non-rebreathing systems have one-
way valves
Table 1: Oxygen delivery devices
Categorization Example Performance Oxygen flow FiO2
based on flow rate (per min) delivered
Nasal cannula Variable 2 – 4 litres* 24 – 35%
Simple face mask Variable 5 – 10 litres 40 – 60%
Low flow device Tracheal mask Variable 5 – 10 litres 40 – 60%
Partial rebreathing mask Variable 4 – 10 litres 35 – 60%
with reservoir bag
Venturi Fixed 3- 15 litres 24 – 60%
High flow device High flow warmed nasal Fixed using 10- 40 litres 40 – 100%
devices blenders
Non-rebreather mask Variable 8 – 10 litres 60 – 90%
with reservoir bag
MANAGEMENT OF RESPIRATORY FAILURE

 The aggressiveness of the approach depends on the patient’s condition
 Broadly, one can get an idea of the severity of the respiratory failure from a combination of
clinical examination (Respiratory rate RR and Pulse oximetry SpO2) of the patient and ABG
abnormalities (Table 2).
 It is important to identify the precipitating cause as mentioned in the earlier section and treat
appropriately-for eg: Chest tube insertion for pneumothorax; antibiotics to treat infection,
bronchodilators and steroids for exacerbation of COPD or the reversal of the central or peripheral
nervous system problem that resulted in hypercapnic respiratory failure
GOALS OF OXYGEN THERAPY
1. Improve oxygenation: target saturation >96% in those without Type 2 respiratory failure and
88-92% in those with hypercapneic respiratory failure

36
2. Decrease the work of breathing: respiratory rate <35 breaths/min and with no use of accessory
muscles of respiration
Table 2: Approach to respiratory failure-COVID cases
RR and PaO2 on Oxygen support and other Where can the patient be
SpO2 Room air management managed?
Mild Tachypneic 60 to 70 Start low and scale up if Ward with close monitoring
(RR 16 to mmHg required based on NEWS2 score
25 pm)
SpO2 92 to Nasal cannula or a venturi Ideally, RR, SpO2 every
96% mask may be sufficient. 2hours
Awake proning
Moderate Tachypneic 50 to 60 Use a high flow oxygen Consider ICU for close
(RR 25 to mmHg device (Table 1) and scale monitoring
35pm) down if patient improving
SpO2 90 to Close monitoring, ideally
94% Non rebreather reservoir -RR, SpO2 every 15 to 30
mask or 60% venturi minutes
High flow nasal cannula If in Ward, monitoring based

(HFNC) @ on NEWS2 score
NIV If RR>35/min OR Watch for features of

P/F*<200 decompensation-can
consider a repeat ABG in an
Awake proning hour
-Paradoxical respiration
-Increasing CO2 with
respiratory acidosis
Severe Tachypenic <50mmHg CALL FOR HELP ICU
(RR
>35/min) Can start with NIV and awake Close monitoring
AND proning -RR, SpO2 every 15 to 30
SpO2<90% minutes
Decision to intubate in this
scenario will depend on:
1. Failure of clinical response
on NIV in the form of
-- Worsening respiratory
acidosis
-- Worsening hypoxemia
--Increasing FiO2>70 to 80%
on NIV
2. Respiratory arrest
@ HFNC availability is limited

37
IMPORTANT PRECAUTIONS REGARDING HFNC AND NIV IN THE WARD
 HFNC and NIV are aerosol generating procedures and preferably not to be offered in
the ward. In exceptional circumstances (ICU bed not available), they can be offered in
airborne precaution rooms in the ward.
o NIV: Viral filter to be put in both inspiratory and expiratory limbs
o If the patient is on HFNC, it is recommended that the patient wears an N95 mask
 Ensure full PPE is worn as per recommendations-head gear, visor, goggles, N95 mask,
disposable waterproof surgical gown and shoe covers at all times
ADDITIONAL MANOUVRES TO IMPROVE OXYGENATION: AWAKE SELF-PRONING
Any patient with ARDS is a candidate for awake proning. This helps improve oxygenation by
improving V/Q (Ventilation/Perfusion) matching.
CONTRAINDICATIONS OF AWAKE SELF-PRONING

 Untrained staff
 Haemodynamic instability(on vasoactive medications): preferable to prone these patients in a
monitored environment; if severe/refractory hemodynamic instability, proning is not advised
 Increased intracranial pressure
 Increased abdominal pressure
 Abdominal, Chest and facial wounds
 Cervical spine precautions
 Extreme obesity
 GCS <8
 Pregnancy 2nd or 3rd trimester
PROCEDURE FOR AWAKE SELF-PRONING
Monitoring
Continuous O2 monitoring is required. ECG leads to be connected to posterior chest wall for
continuous monitoring.
Prior to proning
1. Make plans in advance for toileting, call bell, entertainment, and cellular phone
2. If possible, place the bed in reverse Trendelenburg (head above feet, 10 degrees) to help reduce
intraocular pressure.
3. Have patient empty bladder
4. Educate the patient. Explain the procedure and rationale of the intervention to the patient.
5. Arrange tubing to travel towards the top of the bed, not across the patient, to minimize risk of
dislodging. Ensure support devices are well-secured to the patient. (Ex. Sleeve over IV access
site, position urinary catheter

38
6. Assess pressure areas to avoid skin breakdown- avoid pressure with proning with the use of
pillows/gel pads
Prone position-the procedure
1. The patient should lay on their abdomen (arms at sides or in “swimmer” position).
2. If a patient is unable to tolerate, they may rotate to lateral decubitus or partially prop to the side
(in between proning and lateral decubitus) using pillows or waffle cushioning as needed.
Ideally the patient should be fully proned rather than on the side as there is currently no data
about whether side positioning is beneficial.
3. 15 Minutes after each position change, check to make sure that oxygen Saturation has not
decreased. If it has, try another position.
4. If patient has a significant drop in Oxygen saturation, follow these steps:
i. Ensure the source of the patient's Oxygen is still hooked up to the wall and is properly
placed on the patient (this is a common cause of desaturation)
ii. Ask patient to move to a different position as above
iii. If after 10 minutes, the patient's saturations have not improved to prior levels, consider
escalation of oxygen modality vs. trial of additional positions
Time spent proning
Patient should try proning every 4 hrs, and stay proned as long as tolerated. Proning is often limited
by patient discomfort, but they should be encouraged to reach achievable goals, like 1-2 hours (or as
long as possible).
Ideal duration is 16 hrs per 24 hours (e.g., 4 times for 4 hours each session)
When to stop awake proning?
1. A patient can choose to stop awake proning at any time.

2. In case of hemodynamic instability or if impending respiratory failure, it is recommended that
the clinician stops proning and consider intubation
Additional resources for awake self-proning

For a video to better demonstrate proning positions please visit the following link:
https://www.youtube.com/watch?v=cCkHPYpwg2g

39
MONITORING WHILE ON OXYGEN AND OXYGEN WEANING PROTOCOL

For all patients on oxygen, ensure:
SpO2 monitoring (frequency based on NEWS2 score)
ABG: Daily ABG only for patients on NIV or mechanical ventilation
If ABG reveals improving P/F ratio, consider weaning oxygen by 2 litres at a time and
recheck after 6 hours. If P/F ratio on 2 litres O2 >350, consider stopping oxygen and
monitor both RR and SpO2 every ½ hour to ensure there is no decompensation.
If at any level of supplemental oxygen therapy patient has increasing RR OR dropping SpO2 OR use
of accessory muscles of respiration:
1. Get ABG and calculate NEWS2 Score

2. Increase O2 steadily to a level appropriate to maintain saturation above 94% (unless
contraindicated).
3. Inform the on-floor consultant.
4. Refer to the management protocol for oxygen delivery.
WHEN SHOULD A PATIENT BE SHIFTED TO ICU/HDU?

1. Assessment should be based on a combination of clinical judgement and NEWS2 score
2. Any patient requiring life support: NIV, intubation, inotropes should ideally be in ICU.

40
FLUID MANAGEMENT AND NUTRITION

(Ramya I)
Goal of fluid management – Euvolemia
Key points to remember

1. Avoid dehydration and overhydration.
2. Preferred IV fluid for resuscitation is Normal Saline (0.9 %).
3. Avoid starches – associated with high mortality. Avoid Gelatins – expensive.
4. In patients with ARDS fluid management is conservative.
5. Review the fluid status and the fluid orders daily.
6. Keep in mind the insensible fluid losses and avoid drying out the patient too much
EVALUATION OF FLUID STATUS IN PATIENTS WITH COVID 19

CLINICAL SIGNS
a. Pulse rate
b. Blood pressure
c. Jugular venous pressure
d. Urine output
e. Signs of hypoperfusion: skin mottling, altered sensorium, capillary refill time > 2 sec)
f. Signs of fluid overload: Presence of peripheral edema, lung crackles
DIAGNOSIS ON THE BASIS OF ASSESSMENT
A. Euvolemia/ Mild dehydration

1. Euvolemic patients who can take orally – no IV fluids ,can take their usual diet
2. Mild dehydration due to diarrhea can take orally – ORS 100 ml per stool
3. Patients who cannot take orally require IVF –
a. IVF prescription
i. 25 ml/kg/day or 1 ml/kg/hour (subtract fluid intake from other sources from
this value) containing 1 meq/kg/day K+, 1-1.5 meq/kg/day Na+, 1 meq/kg/day
Cl-
i. 1-1.5 g/kg/day glucose to prevent starvation ketosis (if diabetic, add insulin in
the pint with hourly GRBS monitoring)
ii. Review electrolytes daily and correct
B. Patient in shock
Definition: MAP ≤65 mm Hg and lactate ≥2 mmol/L/peripheral signs of hypoperfusion

41
b. Establish venous access

c. If possible insert a central venous catheter
d. Identify the cause (send labs): ECG, Troponins, ABG for lactates
e. Assess for fluid responsiveness
Test Method
Passive leg raising test Place the patient in the semi-recumbent position at 45°—use the bed
(PLR) adjustment to elevate the lower extremities and lower the head to
neutral position— assess the capillary refill time after 1 minute
Reassess after returning patient to semi recumbent position
If available from pulse oximetry, can use perfusion index – 9% increase
in PI after PLR indicates fluid responsiveness
Central venous Indicative
pressure measurement
f. If fluid responsive and NO ARDS – crystalloids 30 ml /kg within first 2 -3 hours

g. Fluid responsive WITH ARDS – conservative management with lower fluid boluses
- 250 ml in the first 15 mins and reassess for fluid overload; target CVP < 4 mm (if
patient has a CVC).
h. Euvolemic + ARDS – maintenance fluids based on the results of daily monitoring of
fluid and electrolytes
i. Hypervolemia +ARDS – Judicious use of loop diuretics (consider myocarditis)
j. Hypervolemia +ARDS + shock – Noradrenaline is the inotrope of choice
Monitoring of patients on fluid therapy
1. Strict intake output chart

2. Monitor cumulative fluid balance
3. Assess for fluid overload daily
a. 10 % increase in weight gain Start de-resuscitation immediately
b. Or clinical features of fluid over load
4. Fluid stewardship – Daily
a. Does the patient need IV fluids?
b. Should I start IV fluids?
c. Should I stop IV fluids?
d. Should I start removing fluids (Patient overhydrated) – use diuretics
e. Should I stop removing fluids (patient starting to get dehydrated)

42
DIET ORDER FOR THOSE ABLE TO EAT AND DRINK
 Energy: 30 kcal/kg body weight/day

 Protein: 1g/kg/day (will provide 4 kcal/g of protein)
 Carbohydrate and lipid: Calculate from non-protein energy requirement, carbohydrates = 4
kcal/g, lipids = 9 kcal/g; lipid: carbohydrate ratio of 30:70 if no respiratory insufficiency, 50:50
if respiratory insufficiency)
 Electrolytes: See above note on maintenance fluids
 Fluid: urine output + 500 ml
Consider oral nutrition supplements (low volume, high protein) x 2 per day if intake < 50% of food and drink
offered
NG tube insertion is an aerosol generating procedure – avoid if possible, but can be considered if oral intake
expected to be not possible > 3 days or < 50% for 5-7 days. Provide energy dense formula (1.25-1.5 kcal/ml)

43
DIABETES MELLITUS IN RELATION TO COVID-2019

(Nihal Thomas, Felix Jebasingh K)
General principles
1. HbA1c to be sent for all patients with diabetes at admission

2. Target fasting glucose of 110-130 mg/dL and post prandial of 160-180 mg/dL except in CKD
(chronic kidney disease) , CLD (chronic liver disease) and severe CHF (congestive heart
failure, see below)
3. As patient with diabetes can have other co-morbidities, these too need to be managed, but
formal evaluation of diabetic complications can be planned on an outpatient basis.
4. On follow up after discharge, target HbA1C < 7% if possible and definitely < 8%
Recommendations for management of diabetes based on severity of COVID19, glycemic

control and comorbidities
Severity of Monitoring Treatment Titration

illness
Mild cases At least GRBS- Continue current OADs or If on fixed dose
/asymptomatic Fasting and post insulin combination of OADs,
contacts breakfast split the OADs and
glucose increase the dose
individually.
Moderate GRBS- Continue current Increase the insulin by 1
Fasting and post OADs/insulin if glucose is unit for each 25mg/dL
breakfast, post controlled. increase in blood glucose
lunch, post If fasting > 160 mg/dL or post levels above the target
dinner glucose prandial > 250 mg/dL, start range.
pre-mixed insulin (30/70) at ~ If fasting glucose levels
8 units before breakfast and 6 above the target level,
units before dinner. night insulin dose to be
Metformin can be continued if increased, if PP breakfast
patient is not sick, other OADs levels high, morning dose
to be temporarily stopped of insulin to be increased.
Severe See chart below Consider initiating insulin Maintain blood glucose
infusion (see below) between 140-180mg/dl.
Glucose > 250 See chart below Consider initiating insulin Maintain blood glucose
mg/dL & infusion (see below) between 140-180mg/dl.
ketones +
CKD GRBS-Fasting Add bolus insulin (Regular Target fasting glucose of
(Creatinine > 2 and post Insulin) 4 units before each 135-150 mg/dL and post
mg/dL), CLD breakfast, post meal and add on Intermediate prandial 160-200 mg/dL.
or severe CHF lunch, post acting insulin (NPH) as
dinner glucose bedtime , if fasting glucose >
180 mg/dL

44
Insulin titration chart:
GRBS Infusion Rate General instructions

< 100 mg % 0.5 Units/h  Check GRBS every 2 hourly
 Add 1 ml of Regular Insulin (40 Units) to 39 ml of Normal
101-200 mg% 1 Units /h Saline, Hence 1 ml=1 unit
 Check Serum K+ at least 12 hourly and correct as given below,
201-300mg% 2 Units/h provided serum creatinine is normal
3 Units /h < 3.5 meq/dL—Add 3 grams KCL
301-400mg %
3.5 -4.5 meq/dL—Add 1.5 grams KCL
> 4.5 meq/dL—No KCL
401-500mg % 4 Units/h
 Once glucose drops to < 250mg/dL, add simultaneous IV DNS
> 501mg % 5 Units/h and follow the sliding scale for insulin infusion also.
If infusion pump is not available in the ward, start an infusion as follows:
 500 mL 5% Dextrose Normal saline (DNS)

 20 mmol/L (1.5 grams) potassium chloride, provided the renal functions are normal
 8 units of regular/ short acting insulin (eg. Actrapid, Insugen R, Huminsulin R). Add 4-6
units if high serum creatinine.
 Infuse at a rate of 75 to 100 mL/hour and titrate according to the renal and cardiac status.
 Glucometer Glucose (GRBS) to be measured every two hourly.
 Target Blood glucose values – 140-180 mg/dl, can be up to 200mg %
 Disadvantage – inflexibility, as both insulin and dextrose are mixed as a single solution.

45
APPROACH TO A PATIENT WITH RENAL DYSFUNCTION

(Anna T. Valson)
Note: eGFR calculation should be done using the CKD EPI eGFR (per 1.73m2) available in the GFR program under the
‘Protocols/Calculators/FAQs’ section of Intranet. Drug dose calculation should use the Cockcroft Gault calculator (not
adjusted for BSA)
Important don’ts for patients on dialysis
1. Do not take blood samples, put IV lines or measure blood pressure on the AV fistula arm
2. Do not use the dialysis catheter for any infusions except the extra lumen of a triple lumen
catheter
3. Blood samples should be sent pre-dialysis.
4. Do not check creatinine on the day after dialysis, unless urine output is improving and the
idea is to postpone further dialysis. Only potassium is required to be monitored in patients
on dialysis who are oliguric (urine output < 0.5ml/kg/hour for 24 hours), unless otherwise
indicated.
5. If an antibiotic (eg. Meropenem, Piperacillin-Tazobactam) is cleared by dialysis, schedule
the dose post dialysis
6. Restrict fluid intake to previous day’s urine output + 500 ml

46
HYPERTENSION IN COVID19
(Sowmya Sathyendra)
Definition Pharmacological treatment indicated

Normal blood Systolic < 120 and x
pressure diastolic < 80 mm Hg
Elevated blood Systolic 120-129 and x
pressure diastolic < 80 mm Hg
Stage 1 hypertension Systolic 130-139 or Only if one or more of the following:
diastolic 80-89 mm Hg  Established cardiovascular disease (stable
ischaemic heart disease, heart failure, carotid
artery disease, previous stroke, peripheral
artery disease)
 Type 2 diabetes
 CKD
 Age≥ 65 years
Stage 2 hypertension Systolic ≥ 140 or Yes
diastolic ≥ 90 mm Hg
Hypertensive urgency Diastolic > 120 mm Hg Yes; aim to reduce BP to ≤160/≤100 mmHg with
with no acute end-organ oral plain nifedepine 10mg every 6 to 8 hours
damage
Hypertensive Diastolic > 120 mm Hg Urgent BP control with GTN 5 to 100 mcg/minute
emergency and evidence of acute as IV infusion) best done in a monitored area with
end-organ damage target blood pressure of <180/<120 mmHg for the
first hour and <160/<110 mmHg for the next 23
hours
Suggested management:
 Initial choice of antihypertensive: Thiazide-type diuretics: 25mg - 50mg once daily ORlong-
acting dihydropyridine calcium channel blockers (eg. Amlodipine): 5- 10mg once daily
ORangiotensin-converting enzyme (ACE) inhibitors: 2.5mg - 5 mg once/twice a day*
ORangiotensin II receptor blockers (ARBs): 25mg - 50mg once/twice daily *
 Step up treatment: Long-acting ACE inhibitor or ARB + long-acting dihydropyridine calcium
channel blocker OR ACE inhibitor or ARB + thiazide diuretic (may be less beneficial
when Hydrochlorthiazide is used)
*Patients receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
should continue treatment with these agents unless there is an indication for discontinuation such as hyperkalemia
or hypotension. There is no evidence that stopping ACE inhibitors/ARBs reduces the severity of COVID-19

47
HOW TO MANAGE COPD AND ASTHMA IN COVID19
(Ashwin Oliver, Avinash Nair)
COPD EXACERBATION (AEx COPD)
Presentation: A known case of COPD presents with acute worsening of respiratory symptoms
requiring additional therapy
Symptoms: Worsening of breathlessness (common), increase in sputum purulence and volume,

increased cough, wheeze.
STEPS IN MANAGEMENT:
1. Rule out the following differential diagnoses which can both trigger an exacerbation and
mimic one
 Viral/bacterial infection
 Pneumothorax
 Pleural effusion
 Pulmonary embolism
 Pulmonary edema
 Cardiac arrhythmia
2. Assess the severity of the exacerbation
No respiratory ARF- Non-life- ARF- Life threatening

failure threatening
Respiratory rate 20-30 breaths/min >30 breaths/min >30 breath/min
Accessory muscles usage No Yes Yes
Mental status No change No change Acute change
Improvement with Venturi 28-35% Venturi 24-35% Venturi >40%
supplemental O2
PaCO2 No increase Increased from baseline Increased >60mmHg or
50-60mmHg pH ≤ 7.25
Place of management Ward HDU/ ICU HDU/ ICU
ARF = Acute respiratory failure
3. Send investigations
1. ARTERIAL BLOOD GAS- pH, PaO2, PaCO2 levels
2. CBC
3. Creatinine
4. Chest radiograph
5. ECG
6.Cardiac enzymes- CK-MB, Troponin T
7. D-dimer, if chest X ray is normal.
8. If D dimer is elevated and no other obvious cause for breathlessness-CT Pulmonary
angiogram
9. Throat swab for H1N1 Influenza if patient is not improving or deteriorating

48
4. Assess if the patient requires non-invasive ventilation

i. Respiratory acidosis (PaCO2 >45mmHg and pH ≤7.35)
ii. Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased
work of breathing, or both, such as use of accessory muscles, paradoxical breathing, or
intercostal retractions.
iii. Persistent hypoxemia despite supplemental oxygen
5. Assess if the patient requires ICU admission

i. Severe dyspnea that does not respond to initial emergency treatment
ii. Change in mental status- Confusion, lethargy, Coma
iii. Requiring NIV
iv. Persisting or worsening hypoxemia (PO2, 40mmHg) and /or severe/ worsening
respiratory acidosis despite supplemental oxygen and NIV
v. Need for invasive mechanical ventilation
vi. Hemodynamic instability- need for vasopressors
6. Management of a non-life threatening severe exacerbation

i. Controlled oxygen therapy: If SpO2 is less than 88%, start oxygen via nasal prongs or
venturi device. Target SpO2 between 88-92%.
ii. Bronchodilators: MDI Salbutamol 100mcg 2puff every 4- 6 hourly using spacer, MDI
Ipratropium bromide 2puff every 6 hourly using spacer.
iii. Oral corticosteroids: Tab Prednisolone 40mg once daily for 7 days and stop or IV
steroids- Inj Hydrocortisone 100mg IV every 6 hourly.
iv. Antibiotics and antivirals: Tab Co-Amoxiclav 1gm twice daily for 5 days, Tab
Azithromycin 500mg once daily for 3 days, Tab Oseltamivir 75mg twice daily for 5 days
(to stop if throat swab is negative)
v. Anticoagulation: As per ‘Treatment protocol’
7. Assess fitness for discharge

i. Clinically stable condition and no parenteral therapy for 24 hours
ii. Inhaled bronchodilators are required less than four-hourly
iii. Oxygen delivery has ceased for 24 hours (unless home oxygen is indicated)
iv. If previously able, the patient is ambulating safely and independently, performing
activities of daily living, able to eat and sleep without significant episodes of dyspnoea

49
ASTHMA EXACERBATION
Presentation: A known case of asthma presents with worsening of respiratory symptoms requiring
additional therapy
STEPS IN MANAGEMENT
1. Assess if there is a risk for asthma related death
i. A history of near fatal asthma requiring mechanical ventilation and intubation

ii. Hospitalization or emergency care visits for asthma flare up in the last 1 year
iii. Currently using or recently stopped oral corticosteroids
iv. Not currently using inhaled corticosteroids
v. Overuse of short-acting beta2 agonists (>1canister/month)
vi. A history of psychiatric disease or psychosocial problem
vii. Poor adherence to asthma treatment
viii. Food allergy in a patient with asthma
2. Take a quick history for onset of symptoms to rule out alternate causes like
i. Anaphylaxis
ii. Pneumothorax
iii. Cardiac failure
iv. Pulmonary embolism
3. Assess the severity of the exacerbation
Mild or Severe Life threatening

moderate
Speaking Talks in phrases Talks in words Unable to talk
Posture Prefers sitting to Sits hunched forward Sits hunched
lying forward
Accessory muscles usage No Yes
Respiratory rate < 30/min >30/min Silent chest
Mental status Not agitated Agitated Confused, drowsy
Pulse rate 100-120/min >120/min >120/min
SpO2 on room air 90-95% <90% <90%
Place of management Ward Consider HDU/ICU if no ICU
improvement with SABA and
oxygen
SABA = Short acting beta2 agonist

50
4. Treatment
i. Bronchodilator
 MDI with spacer – Salbutamol 100mcg 4-10 puffs via spacer every 20 mins in the
first 1 hour
 If improving can space to same dose 2 hourly, then same dose 4 hourly
 Common side effects: tachycardia, tremors
ii. Oral corticosteroid

 Oral prednisolone 1-2mg/kg/day maximum 50mg/day for 7 days
 Common side effects – disturbed sleep, increased appetite, rise in blood sugars
iii. Controlled oxygen therapy

 Target SpO2 is 95% (NOT 100%)
iv. Antibiotics
 Indicated only if fever, purulent sputum or clinical/radiological evidence of
pneumonia
 Preferred agents: Amoxicillin + clavulanic acid 1g twice daily for 5-7 days,
Azithromycin 500mg once daily for 3-5 days. Oseltamivir 75mg twice daily for 5
days (If Influenza is suspected or test positive)
v. Assess for discharge

 Saturation > 94% on room air
 Symptoms improved, not needing short acting beta2 agonist
vi. Arrange at discharge

 Reliever: MDI Salbutamol as needed
 Controller: Start or step up, check inhaler technique
 Follow up with Respiratory Medicine in addition to Medicine

51
CRITERIA FOR TRANSFER TO KANNIGAPURAM CAMPUS

(O C Abraham)
1. Assess eligibility criteria for admission to Kannigapuram (see below)

2. Inform the Floor Consultant at Kannigapuram (05924)
3. Ambulance to be arranged via Transport Department. Patient to pay charges for ambulance.
Admission criteria to Kannigapuram Campus
1. Laboratory confirmed SARS-CoV-2 infection (COVID-19) in adult (≥18-year age) men and
non-pregnant women
2. Patients referred from CMC Main Hospital or Ranipet District Collector’s / DDHS’s Office
(through the liaison Medical Officer)
3. All the following criteria must be fulfilled
i. Age ≤60 years
ii. Temperature ≤101 °F
iii. Pulse rate ≤100 beats/minute
iv. Respiratory rate <24 breaths/minute
v. Oxygen saturation ≥94% while breathing room air
vi. Conscious, alert, oriented to time place and person
Patients are NOT ELIGIBLE FOR ADMISSION ifany one of the following additional criteria
are present:
i. Age >60 years

ii. Temperature >101 °F (>38.3 °C)
iii. Pulse >100 beats/minute
iv. Respiratory rate ≥24 breaths/minute
v. Oxygen saturation <94% while breathing room air
vi. Glasgow Coma Scale <15
vii. Significant comorbidities
 Coronary artery disease (MI, PCI or CABG within previous 6 months)
 Heart failure (NYHA Class 3 and 4)
 COPD (mMRC Dyspnea Scale Grade 2, 3 and 4)
 Uncontrolled Diabetes (HbA1C ≥9% or random glucose >300 mg/dl)
 Systemic hypertension with systolic BP ≥140 mm Hg or diastolic B ≥90 mm Hg
 Active cancer (Therapy ongoing or within last 6 months)
 Chronic kidney disease (based on history)
 Decompensated chronic liver disease (edema, jaundice, ascites, encephalopathy)
 Transplantation (SOT & HSCT)
 On immunosuppressive treatment currently

52
DISCHARGE CRITERIA
Fever Breath- Oxygen Minimum Exit Home

lessness requirement Time to testing isolation
discharge
Asymptomatic 8 days of No 14 days
positive hospital from date
admission of
discharge
Mild disease Afebrile > No No oxygen 10 days of No 14 days
positive 3 days requirement hospital from date
without admission of
antipyretics discharge
Moderate Afebrile > No SpO2 > 95% 10 days of No 14 days
(needing 3 days without oxygen hospital from date
oxygen without for 4 days after admission of
therapy) antipyretics becoming discharge
afebrile
Severe/Critical Afebrile > No SpO2 > 95% After clinical No 14 days
(including 3 days without oxygen recovery and from date
immune- without for 4 days after at least 10 of
compromised) antipyretics becoming days from discharge
afebrile admission
Note: These guidelines are liable to change from time to time – please follow the updated discharge
criteria as and when they are released
(http://172.16.11.221/misc/corona/PROTOCOLS/PROTOCOLS%20FOR%20PATIENTS/DISCHARGE%20PROTOCOL
S/Discharge%20policy%20for%20covid%20positive%20patients.pdf)

53
NON-ESCALATION / DE-ESCALATION OF CARE
(Anand Zachariah)
Basis of the policy
Patients with COVID-19 who are elderly and/or have significant comorbidities have very poor
outcomes and prolonged ICU stay when ventilated in the intensive care unit. The decision-making
on escalation and non-escalation in such cases will be made by the individual unit on a case by case
basis, by the senior consultants. These decisions will be based on good clinical judgement and in
discussion with the family.
Patients in whom Non-escalation/De-escalation may be considered
Intubation and mechanical ventilation may be generally considered less appropriate in the following
categories of COVID19 patients:
1. Age > 70
2. Age 60 – 70 with significant morbidities such as:
i. Heart failure Class III-IV

ii. COAD Class III-IV
iii. Advanced Chronic Kidney disease
iv. Underlying active malignancy
v. Dementia, other neuro-degenerative disease or stroke
vi. Chronic Liver disease
vii. Other major systemic illness
viii. Poor functional status prior to present illness
In such cases, supportive care may be offered in the ward or ICU as described below.
Supportive care
1. Supportive care in the ward may include treatments except NIV, mechanical ventilation
and CPAP/BIPAP.
2. Supportive care in the ICU may include NIV and inotropes but does not include
mechanical ventilation, dialysis and ECMO
Palliative Care
Please see the appendix for a detailed description of palliative care options.
Concessional care
In case patients cannot afford the cost of care, concessional care may be provided from the unit, PTP
and hospital free bed schemes with contributions from the family to the extent possible. The admitting
unit is requested to check the inpatient bill online daily and request the family to pay periodic advance
according to their financial capability.

54
CPR PROTOCOL
(Binila Chacko)
Consider reversible causes (History and venous blood gas)

• Ward Nurses to ensure that DEFIBRILLATOR is available. Hypovolemia Tension pneumothorax
• CRASH Cart, Viral filter, LMA size 3 (female) and size 4 Hypoxia Tamponade, cardiac
(male), Disposable Syringe (20cc) and lubricant jelly to be Hydrogen ion (acidosis) Toxins
kept ready. Hypo-/hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary
Goal: Early airway securement- if unable to intubate, consider placing LMA for ventilation.
Minimize/Avoid bag-mask ventilation prior to intubation/LMA; if necessary- 2 hand mask
holding to ensure tight seal by the most experienced provider, while the second provider
can assist with bag ventilation.
ENSURE THAT ALL HEALTH CARE PROVIDERS HAVE DONNED PPE APPROPRIATELY BEFORE BAG MASK VENTILATION
 Second provider assist with bag ventilation
 HEPA filter between mask and bag
 If unable to intubate via trachea, consider placing laryngeal mask airway (LMA) for ventilation
 Hold chest compressions while intubating to minimize aerosolization of the virus and infectious risk to resuscitation team

55
COMMUNICATION
(Checklists and guidelines)

56
COMMUNICATION, COMPASSION, AND ETHICAL CARE

(Anand Zachariah)
Introduction
In the midst of the COVID-19 epidemic there are many barriers to providing ethical and
compassionate care for patients suspected to or confirmed to have COVID-19.
These barriers include:
a. Lack of patient autonomy in decisions regarding COVID-19 testing, admission to SARI ward
and choices regarding treatment.
b. Breach of confidentiality in COVID-19 testing may lead to availability of patient’s COVID-19

results in the public domain. This can cause labelling, targeting and stigmatisation in the
community with adverse psychological and social consequences.
c. Anxiety and concerns of health professionals regarding risks of transmission can affect the
quality of care provided.
d. The use of PPE may affect the quality of health worker- patient communication because the
patient may not be able to identify who the health care worker is, they cannot see the facial
expressions of the health worker, there is a lack of physical contact and the duration of
communication is brief.
e. The patient is alone in the ward/ICU and does not have the family to support them. Family
members of COVID-19 positive cases may be home quarantined.
f. The communication by doctors with family members may be only telephonic.
g. In case of the demise of the patient, the government decides the modalities of the last rites.
In the light of these barriers and difficulties, we should take active steps to ensure that our patients
are provided compassionate and ethical care within the hospital guidelines and the government
directives for the provision of care.
The key premises of COVID-19 care that we will provide at CMC are:
1. Highest quality of care

2. Compassionate care
3. Maintaining ethical standards
4. Respecting confidentiality of the patient
5. Striving for good doctor-patient and family communication
6. Ensuring equitable treatment
7. Addressing issues of stigma and discrimination
8. Ensuring safety of the staff
This guideline provides some suggestions toward actualising these premises and addressing barriers.

57
Checklist for communication prior to COVID-19 Testing
 Why COVID-19 testing is required: to improve patient care and to prevent transmission (use
the patient information sheet)
 Implications of a positive and negative result: If positive, patient will be shifted to an isolation
area, family members will not be allowed to visit and may also need to be tested, results will
be shared with the government as required by regulations.
 Reassurance that irrespective of the result, they will be provided the best care.
Checklist for communication at the time of admission to SARI ward
 Explain to the patient and family that this is respiratory isolation ward to reduce risks of
transmission.
 The family cannot be with the patient.
 Health professionals will be wearing full PPE at all times, so they must not get anxious about
this.
Guidelines for daily communication with patients who are admitted in SARI wards and ICU
We should take active steps to communicate effectively in the SARI ward and ICU despite the barriers
of PPE.
1. Introduce yourself when you speak to the patient.
2. Call the patient by name. Find out some personal details. Work towards developing rapport.
3. When the test result is available, this should be conveyed to them.
4. Explain the clinical status and plan to them every day.
5. Ask them if they have concerns. Allay anxiety and reassure the patient. Through the
conversation try and provide emotional support to the best extent possible. Make sure they
know that you want them to get better soon and you have their best interests at heart.
6. Tell them we are communicating with their family every day.
7. Other simple suggestions include: asking relatives to send books, magazines. However these
cannot be shared with other patients, and must be trashed when the patient leaves the ward.
Patient communication with family
Try to ensure that the patient has their cell phone in the SARI ward so they can communicate with
family members through telephone or video calls.

58
Checklist for communication with family members
Prepare yourself for the phone conversation by reviewing the following information: day of
admission, clinical status, lab tests, treatment, prognosis, decisions to be made, bill etc.
1. Before you start speaking, remember: Use small clear sentences, keep your tone low and
your pace slow. Keep a watch on the tone and voice of the person speaking, pause and keep
checking how the person is. Be kind.
2. Introduce yourself
3. Find out who you are speaking to and note down their name. Ask if there is anyone else who
needs to join the conversation.
4. Review with the relative the following:
 Current clinical status and progress
 Lab tests (including COVID-19 test)
 Treatment
 Likely outcome
 Decisions to be made
 Payments
5. If the patient has moderate or severe illness, clarify preferences of the family regarding ICU
care, life support measures such as intubation, ventilation and resuscitation.
6. Answer questions and concerns that the family may have., acknowledge and validate their
feelings/difficulties
7. Ask if there is anybody else in the family who is unwell.
8. Makea note regarding the conversation in the Clinical Work Station including:
 Date and time, name of family member and their relationship with the patient, name
of doctors involved in the conversation, phone number that was contacted.
 Issues discussed
 Decisions made
 Any concerns raised
 Follow-up
9. In case of anticipated death, escalation or non-escalation of care, please follow the guidelines
given in the section on ‘Issues related to death and dying’ that follows.
Access to care and financial support
We should provide for concessional care for patients who cannot afford treatment. We should make
sure all suspected or confirmed COVID-19 are provided the best quality and appropriate care
irrespective of their socioeconomic status. We can provide free food through the Manna scheme for
suspected and confirmed COVID-19 patients and their family who need help. We can access
concessional care through institutional schemes such as PTP, hospital free beds and write offs by
respective units.
Escalation and non-escalation of care
When patients have severe pneumonia as evidenced by hypoxemia or rapid deterioration of

hemodynamic status/consciousness have active discussions with the family regarding escalation of
care. If the patient with COVID-19 is elderly and with multiple co-morbidities, we may actively

59
advise towards non-escalation of care. In case of deterioration, keep the family members informed in
an ongoing manner on the telephone. Try to enable communication between the patient and family
members to the extent that is possible.
Issues related to death and dying
In case death is anticipated, it is important to prepare the family members (use the ‘Bereavement
advice patient information sheet’ in their native language). Ask them if they have specific wishes that
they would like honoured, and their preference regarding prayers and death rites. Explain that
government authorities will make decisions regarding last rites that have to be followed.
If family members cannot be there at the time of death, try to make provision for prayers according
to the religious faith of the person and the wishes of the family. If family members cannot be there to
receive the body from the mortuary because of home quarantine, it would be helpful for a doctor from
the admitting unit to be there at the time of hand over. We can request the help of social workers and
chaplaincy for this.
Communication and joint decision making when death is anticipated

 Rapid deterioration and limited time for decision making can make ethical decision making
particularly challenging for health care professionals and family members.
 Use of the four key ethical principles can serve as a framework.
- Beneficence (do good) and non-maleficence (do no harm) should be considered and the
benefits vs. risk should be weighed for each intervention.
 Patient autonomy should be considered and patient should be involved in decision making.
Always check if the patient would like to be involved in decision making. If the patient does
not want to be involved in decision making, then discussion on goals of care should be done
with the key family members.
 Distributive justice (in terms of resource availability and allotment) should be kept in the
larger perspective of decision making.
 It is important to explore any earlier expressed wishes or preferences on “dying” by the
patient.
 Often most discussions may need to be carried out on telephone/ video conference calls.
 RED-MAP is a useful 6-step approach to guide conversations around planning care in those
with deteriorating health and dying developed in Scotland.
R eady: Assess if the patient / family are ready to talk about the illness and what that means to
them.
E xpect: Explore what patient/ family knows, what they want to know/ fears, concerns?
D iagnosis: Explain what we know / what we don’t know/ not sure about…
M atters: Find out what is important, how they would like to be cared, anything they
specifically want or don’t want.
A ctions: Explain what we can do to help/ options available. What might help and what might
not.
P lan: Make a plan for treatment and care.

60
FINANCIAL ASPECTS OF PATIENT MANAGEMENT

(Chandra Singh)
The Finance Help Desk may be contacted for an opinion on planning the financial aspects towards
care of patients.
This includes:
1. Options to make payment

2. Logistics of payment verification when payment is done without entry in admission slip
3. Outstanding bills and options.
4. Insurance and CMCHIS eligibility.
5. Any other queries related to financial aspects involved in the care of patients.
If your queries are not addressed in the document below, you may either contact Help Desk 6329,
pager 05931 (9385285931) or if there is any difficulty contacting this number, please contact Dr.
Chandra Singh (9442609368).
Questions and answers related to financial aspects of COVID admissions
1. How much advance should I pay?
For non-ICU ward admissions, it costs about Rs.5000/- per day including Bed and Nursing, PPE,
Diet, Basic Tests and medicines. For a 10 days stay, it will come to about Rs.50,000/-. An advance
of Rs.25,000/- is advised.
For ICU admissions, it will cost about Rs.10-15,000/- per day including Bed and Nursing, PPE, Diet,
tests and basic medicines. A 5 days advance of Rs.75,000/- is suggested. If special medicines and
high dose oxygen are required, this will add to the cost.
After five days, advance for another five days is recommended.
2. Where should I pay the advance?
Advance may be paid as
i. Cash in the special cash counter in front of emergency department

ii. Using credit / debit card in the special cash counter in front of emergency department
iii. Through the website, https://clin.cmcvellore.ac.in (If this is being requested, an IP
advance for Rs.25,000/- for general bed and 75,000/- for ICU bed) needs to be
activated through Labmaster in clinical workstation
iv. By NEFT transfer to CMC account – details may be sent either by Whatsapp or by
email. Collect details of email or Whatsapp number to send bank details
v. Deposit into CMC’s bank account from their bank branch. For this also the bank
details need to be sent as before. (Enclosed at the end of the document)

61
3. What if I cannot pay?
All poor patients are given CMCHIS card.
For non-critical patients: We can admit with this card provided the patient is shown in Government
Medical College and authorization letter is obtained. Patient should bring the following documents:
i. The authorization letter from GVMC
ii. Smart Card for CMCHIS
iii. Aadhaar card
iv. Ration card
v. ICMR form
vi. RT PCR result
vii. Patient photograph
viii. Birth certificate in case of children.
Items 1-6 are required at the time of admission and photograph will be taken after admission. The
process should be completed within 24 hours of admission.
For critically ill patients: The authorization letter is not mandatory but the appeal has to be made
within 12 hours after admission and approval obtained within 24 hours of admission with documents
2-7 mentioned above. Please contact the Finance Help Desk to facilitate the same. If you are admitting
with an intention of claiming CMCHIS, please do not collect any advance at the time of admission.
If CMCHIS is approved, we can treat using the scheme and write off the rest of the bill from hospital
subsidy.
4. Is CMC following the Government Regulations of Capped Tariff?
Yes, the general ward charges are capped at Rs.5000/- per day and ICU between 10,000 – 15,000/-
per day for the items advised in the package (Bed charges, nursing charges, Doctors professional
Fees, PPE charges, basic investigations, basic medicines, ventilator charges in ICU). For additional
special tests, medicines and procedures, extra charges will be levied. If COVID test has to be repeated,
extra charges will be levied.
5. What about private bed charges?
This will depend upon shared room or single room. Advance will be Rs.50,000/- and after five days,
additional amount has to be paid depending upon stay.
6. How to decide on patients presenting to emergency or critically ill?

An advance of Rs.75,000/- is recommended for those without CMCHIS card. Options for payment
are to be explained to relatives as in Question 2. After admission, as the medicines are also given
from the IP advance, as and when the bill exceeds the advance paid, the amount has to be topped up
periodically.

62
7. Who gives the admission slips?
For L1 and L2 patients, as the decision is made by the ER doctor, they decide where the patient should
go and give the admission slip, mentioning the amount to be paid (25K for 5 days for L1 and L2, 75K
for ICU). If the payment is done by any of the non-counter options, the slip will not have the proof
of payment. When such a patient lands up to the ward, the admitting sister / ward clerk will call 6239
by intercom or 04162286239 or 9498766329. They will confirm if the payment has been made, and
inform the ward staff and the doctor in the ward will change it to a nil advance slip.
8. Bank details for transfer:
REMITTANCE IN INDIAN RUPEES (WITHIN INDIA)
1. Account Name : CHRISTIAN MEDICAL COLLEGE VELLORE ASSOCIATION

2. Name of the Bank : STATE BANK OF INDIA
3. Branch : VELLORE TOWN BRANCH, CODE : 1618
4. City & Country : VELLORE 632 004, TAMIL NADU, INDIA
5. Account Number : 36889551846
6. Account Type : CURRENT ACCOUNT
7. IFSC / RTGS / IBAN Code: S B I N 0 0 0 1 6 1 8
Note:
1. Please mention the name of the patient and hospital number while transferring the
amount.
2. Please send an e-mail to

(a) care@cmcvellore.ac.in
(b) accounts_banking@cmcvellore.ac.in
(c) billing@cmcvellore.ac.in
(d) ccc.finance@cmcvellore.ac.in
With transfer particulars after the money is transferred.
3. Address for communication

Office of the Treasurer
Christian Medical College
Ida Scudder Road
Vellore 632 004
Tamil Nadu, India
Telephone No. (0416) 2282146, 2286311

63
9. Procedure for entering IP Cash Advance
Figure 1: Tariff code 30001 for IP Cash Advance
Figure 2: Code can also be identified by typing “Cash” and selecting IP cash advance

64
Figure 3: Please choose the amount
Figure 4: Where to go in the patient portal website,

https://clin.cmcvellore.ac.in/webapt/Repeat/Login.aspx
User name: Hospital number, Password: Year of birth

65
Figure 5: Choose from the payments button
Figure 6: Choose mode of payment

66
Figure 7: Options shown
10. How to contact us :

a. Phone:
Finance help desk: 0416-228-6329, 9498766329
Directorate: Mrs. Reena Rani 0416-228-6114
Dr. Chandra Singh: 0416-228-6111
b. Pager: 05931
c. Email:
ccc.finance@cmcvellore.ac.in
dir.fin@cmcvellore.ac.in
chandrasingh@cmcvellore.ac.in
d. Cellphone: Dr. Chandra Singh 9442609368

67
APPENDICES

68
PALLIATIVE CARE IN COVID-19

(Jennifer Jeba)
Learning objectives
1. Identify likely patients who would benefit with integration of palliative care
2. Manage distressing symptoms in Covid-19
3. Provide effective end-of-life care
4. Be aware of nursing needs
5. Offer psychological and spiritual care to patients and families
Introduction
What is palliative care?
“Palliative care is the active holistic care of individuals across all ages with serious health-related
suffering due to severe illness and especially of those near the end of life. It aims to improve the
quality of life of patients, their families and their caregivers.”
Palliative interventions should be integrated with curative treatment. Basic palliative care, including
relief of dyspnoea or other symptoms and psychosocial support, should be provided by all doctors,
nurses, social workers and others caring for persons affected by COVID-19.
Role of palliative care in COVID-19

Provision of palliative care should be considered in patients with severe/ critical COVID-19 illness
to provide adequate symptom control and offer psychosocial and spiritual support.
Patients in whom a decision for non-escalation of treatment (including ICU care, life support
measures such as intubation, ventilation and resuscitation) has been made and documented after
discussion with patient or the family (surrogate) palliative care should be continued.
Palliative care should be provided for such patients to reduce distress and suffering due to physical
symptoms or psychosocial/ spiritual issues, within the limitations brought by the pandemic relating
to time (rapid decline in health), isolation and communication. Palliative care should be provided by
the health care team in the ward in consultation with a palliative care clinician when needed.
This section relates to provision of palliative care for patients where symptoms are significant and/or
survival may not be possible.
**In the effort to reduce staff exposure and optimize care, specialist palliative care consultation
services can be provided through telephone/ video conference with the consultant on call in the
COVID ward 24/7.
Symptom management
Symptom burden in severe/ critical COVID-19 illness could be huge, and urgent/intense symptom
management to provide adequate symptom relief is essential. Symptom management can be done
along with active treatment for COVID-19 including attention to correctable problems.

69
The common symptoms are:
Breathlessness
Cough
Agitation/ delirium
Respiratory secretions
Fever
Pain.
Many patients may experience depression/ anxiety due to a variety of factors.
Approach to any symptom management should include:
 Correcting reversible causes

 Non-pharmacological measures
 Pharmacological measures
Breathlessness
Non-pharmacological measures
 Position - sit upright, legs uncrossed, let shoulders droop, keep head up; lean forward
 Cool room, well ventilated
 Loose clothing
 Cool face with wet cloth
 Avoid use of portable fans/ hand held fans to reduce spread of infection
Oxygen
 There is no role of oxygen in palliating breathlessness in non-hypoxic patients
 In patients with hypoxia - oxygen should be given using the safest mode of administration
 Continue oxygen only if hypoxia improves or patient has symptomatic benefit
Opioids
 Use of morphine (oral or parenteral) should be considered if patient continues to be breathless
despite use of oxygen.
 In those with mild or moderate breathlessness who are able to swallow, start oral morphine
immediate release 2.5-5 mg every fourth hourly and prn
 In those who are significantly breathless or have difficulty swallowing or not fully conscious;
use parenteral morphine (SC - use half the oral dose fourth hourly and prn)
 Dose modifications: Start with a lower dose in the elderly. In those with renal failure give
morphine bd/tid and prn, but fentanyl is preferred.
 Titrate to get adequate symptom relief. Once the dose is titrated, 24 hour dose of morphine
can be given as a SC infusion (prn doses will be 1/6th of the 24 hour dose)
 Consider anxiolytics if patient is agitated or in panic; add lorazepam 0.5-1 mg SL bd and prn
or midazolam 1.5-2 mg SC
 Monitor for symptom relief, excessive drowsiness, side effects.
**While starting morphine – consider using an anti-emetic metoclopramide 10 mg tid or Haloperidol

0.5 mg bd for the first 3 days
**Add Bisacodyl 10 mg hs OD to ensure regular bowel movement while on opioids

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**Avoid nebulisation, fans and suction to reduce spread of infection
Cough
 Good cough etiquette to reduce cross transmission of infection

 Appropriate disposal of tissues with clinical contaminated waste
 Clean hands with soap and water, alcohol-based hand rub after coughing
 Elevate the head end
 Drink warm water
 Use of lozenges
Pharmacological measures
 Simple linctus 5-10mg PO qds

 If not effective, codeine linctus 30-60mg PO qds
 If not helpful, small doses of oral morphine immediate release 2.5 -5 mg every 4 hours and
prn (if able to take orally)
 If patient is at end of life, morphine SC 1.5- 2 mg every 4 hourly will help (if already on
morphine for breathlessness then that should help with cough, titrate the dose)
Agitated delirium
 Well lit, ventilated room

 Presence of a familiar person may not be possible
 Frequent telephone/ video calls from family should be encouraged
Pharmacological measures
 Haloperidol 0.5- 1.5 mg as SC boluses bd or tid(or as continuous SC infusion 5-10 mg over

24 hours)
 If agitation persists, consider midazolam 1-2 mg SC (repeat every 1-2 hours as needed, or a
continuous SC infusion of 5-10 mg over 24 hours)
Respiratory Secretions
 Excessive oropharyngeal secretions and noisy secretory breathing can be present at end of life
 Position the patient on side/ semi-prone position with head turned to one side to facilitate
postural drainage
 Reduction in volume of fluids given can help reduce secretions
 Use anti-secretory drugs early on - Hyoscine butyl bromide 20 mg SC 8th hourly can reduce
this symptom.

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Pain
 Assess the severity and cause of pain: analgesics are given based on the severity of pain
 Mild pain – Tab Paracetamol 1 gm Q6-8 hourly
 Moderate pain – Tab Tramadol 50-100 mg Q6-8 hourly and prn (max 400 mg / day)
 Severe pain – Start with Tab Morphine 5 mg (Immediate release) Q4H and prn and titrate
 Titrate to get adequate symptom relief. Start with lower dose in the elderly
 Follow instructions under the section ‘Breathlessness – opioids’ for options in renal failure
and supportive medications to treat emesis and constipation.
Nursing Care
1. Eye Care
 Clean eyes with swabs soaked in saline from inner to outer canthus
 If the patient is not responsive eyes can be taped with protective pads
 Use lubricant eye drops to prevent dryness of eye
2. Oral Care
 Routine active oral care should be avoided to reduce risks to health care professionals.
Provide limited oral care if there is distress warranting oral care.
 Clean with saline
 Gentle brushing
 Use long swabs to apply moisturizer/ lubricants
 If patient is awake moisten the mouth with drops of coconut oil
 Sip small amounts of clear fluids as frequently as possible to prevent dry mouth
3. Skin care
 Moisturize skin with lotions and cream
 Inspect pressure areas to identify pressure injury (twice every day)
 Re-position every two hours if on regular mattress (every four hours if on pressure re-
distributing mattress)
 Check for pressure injury and repositioning can be made less frequent when the patient
is actively dying
 In case of pressure sores clean with saline and apply antibiotic cream
4. Catheter care
 Use soap and warm water to clean the perineal region and pat dry
 Secure the indwelling catheter to the thigh with a strap or adhesive tape without any
pull on the catheter
 Clean the catheter twice a day using antiseptic solution (betadine)
 Empty the urine collection bag – as soon as it is half-full

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5. Feeding
 Feeding near end of life has not been shown to improve patient symptoms, sense of
well-being and time to death. Reassess the volume of parenteral fluids given and give
fluids based on risks and benefits.
 Allow frequent small feeds/ small sips of clear fluids – to the extent the patient is able
to take. Ensure correct positioning and swallowing techniques to reduce risk of
aspiration.
 Insertion of nasogastric tube is a high-risk procedure and should be avoided/
discouraged as much as possible
 Stop or reduce intravenous fluids or tube feeding in the terminal phase.
Psychological and Spiritual care

Patients with COVID19, especially if hospitalized can experience depression/ anxiety due to concerns
of their own health, physical isolation, health of others in family who need care, risk of death etc.
Basic psychological and spiritual support should be provided for all COVID19 patients. Their
concerns should be explored and heard. This can be done through telephone/ video conferencing.
Where possible try to facilitate communication between patient and family members through phone
and videoconferencing. Where the patient is too sick to communicate, you may be able to allow
families to see their loved ones through videoconferencing.
End of life
 Existing symptoms can worsen at end of life

 Patient may require a continuous subcutaneous infusion of different medicines to help with
refractory breathlessness, agitation or delirium if not controlled with standard treatment
 A combined continuous infusion of morphine (10-30 mg), midazolam (10-20 mg) and
haloperidol (5 mg) can be given (doses of each of these drugs could be guided by the
predominant symptom). Hyoscine butyl bromide (20-60 mg) could be added to the same
infusion if there is noisy secretory breathing
 Advice from the palliative care clinician should be obtained
 Consider smaller doses in the elderly and those with renal failure.
Subcutaneous administration of medications
 Sites for administration of subcutaneous injections include; infraclavicular region, upper outer
area of the arm, abdomen (except two inch area around the umbilicus)
 In situations where subcutaneous injection is not feasible, useful or contraindicated (anasarca
etc.) intravenous administration can be considered.

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References and suggestions for further reading
1. Radbruch L, et al. Redefining Palliative Care –a New Consensus-based Definition, Journal

of Pain and Symptom Management (2020),
doi: https://doi.org/10.1016/j.jpainsymman.2020.04.027
2. COVID-19: Effective communication for professionals. Available at
https://www.ec4h.org.uk/covid-19-effective-communication-for-professionals/
3. Using RED MAP- Talking about Planning Care , Death and Dying. Available at
https://vimeo.com/rcpsg/review/411336060/a082f4c88d
4. COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care. Available
at https://apmonline.org/wp-content/uploads/2020/04/COVID-19-and-Palliative-End-of-
Life-and-Bereavement-Care-20-April-2020-2.pdf

74
NIV AND MECHANICAL VENTILATION IN COVID-19

(Binila Chacko)
Glossary of terms:
NIV = Non-invasive ventilation
CPAP = Continuous positive airway pressure, a mode of non-invasive ventilation
BiPAP = Bi-level positive airway pressure, a mode of non-invasive ventilation with a separate
pressure setting for inspiration (IPAP) and expiration (EPAP)
NON-INVASIVE VENTILATION IN THE WARD
Indications: When should this be considered? Contra-indications:
• ACUTE RESPIRATORY FAILURE • Any indication for intubation-Severe hypoxemia

•-RR>30/Min with moderate to severe dyspnea • GCS<8-Inability to protect airway
•-Use of accessory muscles • Fixed upper airway obstruction
•-Paradoxical breathing • Cardio-respiratory arrest
•-PaCO2>45mmHg with pH<7.35 • Copious secretions/ inability to clear
•-PaO2<60 mmHg with P/F < 200mmHg • Ileus / obstruction
• Copious vomiting, UGI bleed, Epistaxis
• Recent extensive facial surgery/trauma
Relative contraindications:
• Lack of expertise to manage NIV in the ward

(could use as a bridge)
• Confused, agitated patient
• Unstable hemodynamics
• Pneumothorax
• Recent UGI surgery
• Facial deformity
PATIENT PRE-REQUISITES TO START NIV:

• GCS >8
• Should be able to co-operate with the mask
• Should have spontaneous breathing
• Should have good cough reflex(To clear bronchial secretions)

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TECHNICAL PRE-REQUISITES TO START NIV

Machine:
This can be done either with a BiPAP machine or with a regular ventilator (NIV mode).
Interfaces:
• Oro-nasal mask
• Full facial mask
• Helmets
HOW SHOULD THE MACHINE BE SET?

Before initiation of NIV:
• SPEND TIME TO REASSURE PATIENT

• Head-end of the bed elevated
• Mask is held gently on the patient’s face-you could ask the patient to hold the mask and then
gradually increase the pressure.
STEP 1: Select the mode-This depends on the available device:

• CPAP (FiO2 and PEEP)
• Indicated for Type 1 Respiratory failure
• BIPAP [FiO2, EPAP (Expiratory positive airway pressure) and IPAP (Inspiratory positive
airway pressure)]
• Indicated for Type 2 Respiratory failure
• In some machines, you will see different modes: S; S/T; T; AVAPS etc
• Preferable to put the patient on S/T mode which stands for
Spontaneous/Timed mode
• NIV mode on ventilator
• FiO2, PEEP (Positive end expiratory pressure) and PS (Pressure support) are set
• Can be used for both hypoxemic and hypercapneic respiratory failure
Remember FiO2 and PEEP take care of oxygenation. In BiPAP machines, EPAP is a surrogate for
PEEP
Pressure Support (PS )is what helps generate tidal volume and hence takes care of minute ventilation
and carbon dioxide levels. In BiPAP machines, IPAP is a surrogate for PS. IPAP=PS+PEEP
Remember on a BiPAP machine: FIO2 is variable with IPAP and Oxygen flow rate
• If IPAP increases then delivered FiO2 decreases (inverse relationship with IPAP level) –see
Table 1 below

76
Table 1: FiO2 variability based on IPAP and oxygen flow rate
IPAP (cm H20) Oxygen Flow FiO2

(liters per min)
10 2 0.29
5 0.44
15 2 0.27
5 0.385
20 2 0.26
5 0.37
25 2 0.235
5 0.33
30 2 0.23
5 0.32
STEP 2: Settings to be appropriately done

BASELINE SETTINGS:
MODE: CPAP/BIPAP (S/T)/NIV mode on the ventilator
EPAP-5 cm H2O & IPAP-5 cm H20.
HOW TO TITRATE THE EPAP/IPAP SETTINGS?

• Titrate FiO2 /EPAP to achieve SpO2>90%.; EPAP may be increased gradually; normally
do not go beyond 10 cm
• Titrate IPAP – this may be gradually increased as tolerated and based on response; can
go up to 15 cm (increments of 2-3 cm at a time) if any of the following clinical markers:
• Patient distress (clinical evidence of use of accessory muscles)
• Increasing Respiratory rate (RR)
• Heart rate(HR) (note bradycardia in this setting is impending respiratory arrest)
• ABG showing respiratory acidosis
MONITORING WHILE ON NIV:
• Clinical: patient comfort, level of consciousness, chest wall motion, use of accessory
muscles, coordination with ventilator
• RR, HR, EXPIRED TIDAL VOLME
• Decreasing respiratory rate is a good bedside indicator of response to NIV
• Decreasing heart rate is an indicator of response to NIV
• Note: bradycardia in this setting could also indicate impending respiratory
arrest
• Arterial blood gas monitoring 1 hour after initiation and then 8 hours later
• Improvement in oxygenation P/F ratio
• Improvement in respiratory acidosis
• Spo2 monitoring- 85-90%

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NIV TROUBLE SHOOTING - CALL FOR HELP!
HYPOXIA:
• Increase O2 flow/FiO2
• Increase EPAP
• Increase Inspiratory time (Ti)- this can be done by adjusting expiratory trigger
sensitivity-for longer Ti-set ETS close to 0%
• Intubation and ventilation if worsening respiratory distress or respiratory acidosis
• MUST ASCERTAIN CAUSE OF HYPOXIA
HYPERCARBIA:
 Is there a leak- check interface, circuit and connections?

 Increase Pressure support/IPAP
o Is the tidal volume increasing with this manipulation?
o Generally if PS requirement is over 15cm water, assess if the patient
requires intubation
 Assess for re-breathing
o Make sure filters are not blocked
o Ensure that the expiratory port is not blocked
DYS-SYNCHRONY:
• Is the patient anxious?
• Is there a leak >25 litres/min?
• Does the patient have a high ventilatory drive?
 Check settings
o Can the inspiratory time be prolonged by decreasing the expiratory
trigger sensitivity (ETS) on the ventilator
 Increase the peak flow rate
INTUBATION in COVID-19 (indications for intubation are given in Table 2 of the section on
respiratory failure)
1. This should be done by the most experienced member of the team
2. Please ensure that full PPE (Visor/goggles/N95 mask and full sleeved disposable gown and
gloves) is worn.
3. Ensure HIGH EFFICIENCY HYDROPHOBIC FILTER placed between facemask and

Bain’s circuit or between facemask and Laerdal bag.
4. Ideally rapid sequence induction (RSI) is advised.

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a. Pre-treatment with Fentanyl 2mcg/kg followed by induction with Midazolam

0.2mg/kg or Propofol 1-2mg/kg. Ketamine 2mg/kg to be given if the patient is
hemodynamically unstable.
b. If experienced airway skilled personnel is available, paralysis with Suxamethonium

1-1.5mg/kg or Rocuronium 1-1.2mg/kg can be given immediately after sedation.
5. AVOID MANUAL VENTILATION-NO BAGGING THE BAINS! ONLY HOLD THE

MASK TIGHT ON THE FACE
a. Five minutes of pre-oxygenation with oxygen 100% and RSI in order to avoid
manual ventilation and potential aerosolization of infectious respiratory droplets
b. If manual ventilation is required, apply small tidal volumes only.
6. Use of VIDEOLARYNGOSCOPY is preferable

7. Intubate and confirm correct position of tracheal tube.
CARE OF THE INTUBATED COVID 19 PATIENT: BROAD OVERVIEW

1. Ventilated patients:
a. Use dual limb ventilator with filters placed at the ventilator outlets
b. Use heat-moisture exchanger (HME) with HME placed between exhalation port and
mask
c. Place a filter between resuscitator and mask or artificial airway;
d. Closed suction catheter is recommended and it can be used for one week or till it is
visibly contaminated and soiled
e. Dual-limb heated wire circuits are recommended and only changed with visible
soiled (not available in MICU at the moment)
f. Avoid unnecessary bronchial hygiene therapy
g. Low tidal volume 4to 6ml/kg predicted body weight, High PEEP>10cm water;
Allow for permissive hypercapnia (pH>7.20) and aim for Plateau pressures of 25 to
30 cm water
2. Transportation:
a. For patients who need breathing support during transportation, placing an HME
between ventilator and patient
3. Weaning:
a. PSV is recommended for implementing spontaneous breathing trial (SBT), avoid
using T-piece
4. Tracheostomy patients:
a. HME should be used, avoid using T-piece or tracheostomy mask
5. For patients who need aerosol therapy, dry powder inhaler metered dose inhaler with spacer
is recommended

79
INFORMATION
SHEETS

80

Vellore
INFORMATION: - PATIENTS WHO ARE ADMITTED WITH SUSPECTED OR PROVEN COVID 19
Introduction
Individuals who develop Severe Acute Respiratory Illness need to be admitted in a hospital and given care until
the illness resolves. Such patients undergo several tests including a test for COVID19. Many patients and their
relatives are highly concerned about the hospital admission, COVID19 testing etc. and many procedures may be
confusing for them. This sheet provides relevant information on this aspect so that the patients and their relatives
understand what is happening and know what will be done and what to expect during the course of treatment.
1. What is COVID 19?

 COVID 19 is a new viral infection caused by the virus SARS CoV2 which originated in China and has spread
to most countries in the world over a short period of time.
COVID 19 - Diagram
2. How does COVID 19 spread?

 The virus that causes COVID19 is highly infectious.
 When an infected person coughs or sneezes or talks loudly, small droplets from the nose and mouth may
reach another person standing less than 1 meter away.
 These droplets also fall on objects and surfaces around the person and others then get COVID-19 if they
touch these objects or surfaces, and then touch their eyes, nose or mouth.
 This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick and to wash
hands frequently.
3. What are the symptoms of COVID 19?
 The symptoms of COVID 19 are fever with sore throat, cough, breathlessness, diarrhea, or loss of smell or
taste.

81
 Other symptoms are running nose, body pain and weakness.

 The severity of the COVID 19 varies from patient to patient.
o Mild illness: The majority of people who are infected (85%) have mild symptoms such as cough, cold,
sore throat and fever.
o Moderate illness: 15% of patients may have breathing difficulty requiring admission into hospital and
oxygen therapy.
o Severe illness: About 5% become sick with severe breathlessness requiring admission to the ICU and
ventilator treatment.
 Older persons and persons with pre-existing medical conditions (high blood pressure, heart
disease, lung disease, cancer, diabetes, and kidney disease) appear to develop serious illness more
often than others.
 It is important to understand that the information given above is what is seen generally. However,
this is an unpredictable disease, and a patient’s condition can change rapidly, without much
warning.
 Regardless of whether the illness is mild or severe, the treating team will closely monitor all
patients and update the relatives frequently.
4. What tests will be performed to diagnose COVID 19?

 A sample from the throat will be taken through the nose; this sample will be tested for the COVID 19 virus.
The results will usually be available in 24 hours.
 If the test is positive, it confirms the diagnosis of COVID 19 pneumonia.
 If the test is negative, it usually rules out COVID 19 pneumonia.
 If COVID19 pneumonia is strongly suspected, the test may have to be done again if it is initially negative.
 Other routine tests will be done such as blood tests, chest X-ray and ECG.
 The COVID 19 results will be communicated to the government authorities to initiate public health
measures as required by the government.
5. What type of treatment will be given to the patient?

 The patient will initially be treated with appropriate antibiotics.
 If their oxygen levels are low, they may require oxygen therapy with nasal prongs (tube in the nose) or
through a face mask.

82
Oxygen therapy
Oxygen Therapy via face mask Oxygen Therapy via nasal prongs
 Other drugs that they may have been receiving for other medical conditions (e.g. diabetes etc.) will be
continued.
 There is no proven treatment for COVID19. However there are drugs that have been tried in different
centers across the world. These drugs are part of the national protocol for treatment in India and are quite
safe. If the COVID 19 test is positive for the patient, after discussion with patient and relatives treatment
with these drugs will be initiated.
 If the patient becomes very sick, and needs the assistance of a machine (ventilator) to breathe, the patient
may have to be shifted to the Intensive care unit (ICU) for monitoring and treatment. This will greatly
increase the cost of care. The relatives will be asked as to whether they would like to proceed with ICU care
and other life supporting treatments such as ventilator treatment before the patient is shifted to ICU.
Ventilator Therapy
Non-invasive Invasive (Intubation)

6. Admission to Isolation ward -Why
 If a person is COVID19 positive, he/she can spread the infection to health care workers, other patients and
members of the family who visit them. So they need to be in an isolation ward to minimize this risk. If the
COVID 19 test result is negative, the patient will be shifted to a regular ward.
 If the COVID 19 test is positive, the patient will remain in the isolation ward till they improve and the test
turns negative.
7. What are the chances that my patient will recover?

 The COVID 19 infection has a good outcome and is cured in about 97% of patients.
 Patients with mild symptoms (fever, cough or sore throat) do uniformly well.
 Patients who require oxygen and are admitted in ICU, have a serious disease and a higher risk to life.

83
 The treating doctor will explain the chances of patient recovery to the patient and the relatives when
he/she speaks to them.
8. What is the risk of disease for relatives of a patient?

 If the COVID 19 test is negative, then there is no risk to any family members.
 If the COVID 19 test is positive, family members who have been in contact with the patient are advised to
quarantine (isolate) themselves at home.
 They will not be allowed to stay on the premises of the hospital.
 The measures we would strongly advise for the relatives to follow are:
o Wear a mask
o Make sure you, and the people around you, cover your mouth and nose with your bent elbow or a tissue
paper when you cough or sneeze. Then dispose the used tissue paper immediately.
o Minimize close physical contact with other family members.
o Maintain at least 1 meter (3 feet) distance between yourself and anyone who is coughing or sneezing.
o Regularly and thoroughly clean your hands with soap and water or an alcohol based hand-rub
o Avoid touching your eyes, nose, and mouth with unwashed hands.
o Do not leave the premises of the house for 14 days.
o Avoid having any unnecessary visitors.
o If you develop cough, fever, or breathing difficulty you must come to the hospital
o Stay in a separate room at home if that is possible.
o Use separate bathrooms/toilets if possible.
o Do not share plates, spoons, glass. Do not share towels and bedsheets.
o Wash your clothes separately.
9. Meeting with the patient

 Relatives will not be allowed to meet the patient when they are admitted in the isolation ward or ICU.
 This is to reduce risk of infection to family members.
 However, patient will be allowed to speak to relatives by phone, when the patient’s condition is OK.
10. Communicating with the doctors

 If the relatives are staying in the hospital, the doctors will either meet them in person or talk to them on the
phone at least once a day.
 If the relatives are not staying in the hospital, the doctors will speak to them by phone, at least once a day
 Doctors will explain about the clinical condition, progress of treatment, tests that are done and the process
of recovery.
 If any decisions are to be made, the doctors will explain the situation and discuss with the relatives
 If the patient becomes sicker, treating team members will contact the relatives on the phone as soon as
possible.
 When the patient is discharged from hospital clear instructions will be given as to what to do after reaching
home.

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கிருத்துவ மருத்துவ கல் லூரி

வவலூர்
வகோவிட் 1 9 ததோற் று உள் ள அல் லது உள் ளதோக கருதபடும் நபர்

மற் றும் அவர் உறவினருக் க ோன தகவல் தோள்
அறிமுகம்
கடுமையான சுவாச ந ாமய உடல் ல குமைவு உள் ளவர்கள் ைருத்துவைமனயில்

அனுைதிக்க நவண்டுை் ைை் றுை் ந ாய் தீர்க்கப் படுை் வமர கவனிப் பு ககாடுக்க நவண்டுை் .
இத்தமகய ந ாயாளிகள் நகாவிட்19 உட்பட பல நசாதமனகளுக்கு உட்படுகிைார்கள் . பல
ந ாயாளிகள் ைை் றுை் அவர்களது உைவினர்கள் ைருத்துவைமனயில் அனுைதி, நகாவிட்19
நசாதமன நபான் ைவை் றில் அதிக அக்கமை ககாண்டுள் ளதால் , பல மடமுமைகள்
அவர்களுக்கு குழப் பைாக இருக்கலாை் . இ ்த தாள் இ ்த அை் சத்மதப் பை் றிய கபாருத்தைான
தகவல் கமள வழங் குகிைது, இதனால் ந ாயாளிகள் ைை் றுை் அவர்களது உைவினர்கள் என் ன
டக்கிைது என் பமதப் புரி ்துககாண்டு, என் ன கசய் யப் படுவார்கள் ைை் றுை் சிகிச்மசயின்
நபாது என் ன எதிர்பார்க்கலாை் என் பமத அறி ்து ககாள் வார்கள் .
11. வகோவிட் 19 என்றோல் என்ன?
 நகாவிட்19 என் பது சார்ஸ் நகாவி2 என் ை மவரஸால் ஏை் பட்ட ஒரு புதிய மவரஸ்
கதாை் று ஆகுை் . இது சீனாவில் நதான் றியது.குறுகிய காலத்தில் உலகின்
கபருை் பாலான ாடுகளுக்கு பரவியுள் ளது
நகாவிட்19- வமரபடை்
12. வகோவிட் 19 எவ் வோறு பரவுகிறது?
 நகாவிட்19 ஐ ஏை் படுத்துை் மவரஸ் மிகவுை் எளிதில் பரவுை் கிருமியாகுை்

 பாதிக்கப் பட்ட பர் இருைல் அல் லது துை் முை் நபாது, மூக்கு ைை் றுை் வாயிலிரு ்து
சிறிய துளிகள் 1 மீட்டருக்குை் குமைவாக ிை் குை் ைை் கைாரு பமர அமடயக்கூடுை் .
 இ ்த ீ ர்த்துளிகள் பமரச் சுை் றியுள் ள கபாருள் கள் ைை் றுை் நைை் பரப் புகளிலுை்
இைங் குகின் ைன, பின் னர் ைை் ைவர்கள் இ ்த கபாருள் கள் அல் லது நைை் பரப் புகமளத்
கதாட்டு பின் னர் மக கழுவாைல் கண், மூக்கு ைை் றுை் வாமய கதாடுவதன் மூலை்
இ ்த மவரஸ் பரவுகிைது
 இதனால் தான் ந ாய் வாய் ப் பட்ட ஒருவரிடமிரு ்து 1 மீட்டருக்கு (3 அடி) அதிகைாக
தள் ளி இருக்க நவண்டுை் ைை் றுை் அடிக்கடி மககமள கழுவ நவண்டுை் என் பதுை் மிக
முக்கியைாகுை் .
13. வகோவிட்19 வநோயின் அறிகுறிகள் என்ன?
 நகாவிட் 19 ந ாயின் அறிகுறிகள் காய் ச்சல் கதாண்மட புண், இருைல் , மூச்சுத்

திணைல் , வயிை் றுப் நபாக்கு அல் லது வாசமன அல் லது சுமவ இழப் பு.
 ைை் ை அறிகுறிகள் சளி, உடல் வலி ைை் றுை் பலவீனை் .

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 நகாவிட்19 ந ாயின் தீவிரை் ந ாயாளிக்கு ந ாயாளிக்கு ைாறுபடுை் .

 வலசோன வநோய் : பாதிக்கப் பட்டவர்களில் கபருை் பாநலார் (85%) இருைல் , சளி,
கதாண்மட புண் ைை் றுை் காய் ச்சல் நபான் ை நலசான அறிகுறிகமளக்
ககாண்டுள் ளனர்.
 மிதமோன வநோய் : 15% ந ாயாளிகளுக்கு ைருத்துவைமன ைை் றுை் ஆக்ஸிஜன்
சிகிச்மசயில் அனுைதி நதமவப் படுை் சுவாச சிரைை் இருக்கலாை் .
 கடுமமயோன வநோய் : ஐ.சி.யு ைை் றுை் கவன் டிநலட்டர் சிகிச்மசயில் அனுைதி
நதமவப் படுை் கடுமையான மூச்சுத் திணைலால் சுைார் 5% நபர்
ந ாய் வாய் ப் படுகிைார்கள் .
 வயதானவர்கள் ைை் றுை் முன் நப இருக்குை் ைருத்துவ ிமலமைகள் உள் ளவர்கள்
(உயர் இரத்த அழுத்தை் , இதய ந ாய் , நுமரயீரல் ந ாய் , புை் றுந ாய் , ீ ரிழிவு ந ாய்
ைை் றுை் சிறு ீ ரக ந ாய் ) ைை் ைவர்கமள விட கடுமையான
ந ாய் வாய் ப் படுகிைார்கள் .
 நைநல ககாடுக்கப் பட்ட தகவல் கள் கபாதுவாகக் காணப் படுகின் ைன என் பமதப்
புரி ்துககாள் வது அவசியை் . இது ஒரு கணிக்க முடியாத ந ாய் , நைலுை்
ந ாயாளியின் ிமல மிகவுை் எச்சரிக்மகயின் றி விமரவாக ைாைக்கூடுை் .
 ந ாய் நலசானதா அல் லது கடுமையானதா என் பமதப் கபாருட்படுத்தாைல் ,
சிகிச்மசயளிக்குை் குழு அமனத்து ந ாயாளிகமளயுை் உன் னிப் பாகக்
கண்காணித்து , உைவினர்களுக்கு ிமலைமய கூறிய வண்ணை் இருப் பர்.
14. வகோவிட்19 கண்டறிய என்ன வசோதமனகள் தசய் யப் படும் ?
 கதாண்மடயிலிரு ்து மூக்கு வழியாக ஒரு ைாதிரி எடுக்கபடுை் ; இ ்த ைாதிரி

நகாவிட்19 மவரஸுக்கு நசாதிக்கப் படுை் . முடிவுகள் கபாதுவாக 24 ைணி ந ரத்தில்
கிமடக்குை் .
 நசாதமன ந ர்ைமையானதாக இரு ்தால் (பாசிடிவ் ), இது நகாவிட்19
ிநைானியாமவக் உறுதிப் படுத்துகிைது.
 நசாதமன எதிர்ைமையாக இரு ்தால் (க கடிவ் ), இது வழக்கைாக நகாவிட்19
ிநைானியாமவ ிராகரிக்கிைது.
 நகாவிட்19 ிநைானியா இருக்குை் என் று கடுமையாக ச ்நதகித்தால் , ஆரை் பத்தில்
எதிர்ைமையாக இரு ்தால் நசாதமன மீண்டுை் கசய் ய நவண்டியிருக்குை் .
 இரத்த பரிநசாதமனகள் , ைார்பு எக்ஸ்நர ைை் றுை் ஈ.சி.ஜி நபான் ை பிை வழக்கைான
நசாதமனகள் கசய் யப் படுை் .
 அரசாங் கத்திை் குத் நதமவயான கபாது சுகாதார டவடிக்மககமளத் கதாடங் க
நகாவிட்19 முடிவுகள் அரசாங் க அதிகாரிகளுக்குத் கதரிவிக்கப் படுை் .
15. வநோயோளிக் கு எந் த வமகயோன சிகிச்மச அளிக்கப் படும் ?
 ஆரை் பத்தில் ந ாயாளிக்கு கபாருத்தைான நுண்ணுயிர் எதிர்ப்பிகமளக் ககாண்டு

சிகிச்மசயளிப் நபாை் .
 ஆக்ஸிஜன் அளவு குமைவாக இரு ்தால் , அவர்களுக்கு ாசி முமனகளுடன் (மூக்கில்
குழாய் ) அல் லது முககவசை் மூலை் ஆக்ஸிஜன் சிகிச்மச நதமவப் படலாை்
ஆக்ஸிஜன் சிகிச்மச
முககவசை் வழியாக ஆக்ஸிஜன் ாசி முமனகள் வழியாக ஆக்ஸிஜன்

சிகிச்மச சிகிச்மச

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 கூடுதலாக, பிை ைருத்துவ ிமலமைகளுக்காக (எ.கா. ீ ரிழிவு நபான் ைமவ) அவர்கள்

கபை் றிருக்கக்கூடிய பிை ைரு ்துகளுை் ககாடுக்கபடுை் .
 நகாவிட்19 ந ாய் க்கு ிரூபிக்கப் பட்ட சிகிச்மச எதுவுை் இல் மல. இருப் பினுை் உலகை்
முழுவதுை் கவவ் நவறு மையங் களில் முயை் சிக்கப் பட்ட ைரு ்துகள் உள் ளன
 இ ்த ைரு ்துகள் இ ்தியாவில் சிகிச்மசக்கான நதசிய க றிமுமையின் ஒரு
பகுதியாகுை் , அமவ மிகவுை் பாதுகாப் பானமவ. ந ாயாளி ைை் றுை் உைவினர்களுடன்
கல ் துமரயாடிய பின் னர், நகாவிட் 19 நசாதமன ந ாயாளிக்கு சாதகைாக இரு ்தால்
இ ்த ைரு ்துகமளத் கதாடங் கபடுை் .
 ந ாயாளி மிகவுை் ந ாய் வாய் ப் பட்டிரு ்தால் , சுவாசிக்க ஒரு இய ்திரத்தின்
(கவன் டிநலட்டர்) உதவி நதமவப் பட்டால் , கண்காணிப் பு ைை் றுை் சிகிச்மசக்காக
அவர்கமள தீவிர சிகிச்மச பிரிவுக்கு ைாை் ை நவண்டியிருக்கலாை் , இது பராைரிப் பு
கசலமவ கபரிதுை் அதிகரிக்குை் .
 ந ாயாளிமய ைாை் றுவதை் கு முன் , நதமவப் பட்டால் , ஐ.சி.யூ பராைரிப் பு ைை் றுை்
கவன் டிநலட்டர் சிகிச்மச நபான் ை பிை வாழ் க்மக துமண சிகிச்மசகளுடன் கதாடர
விருை் புகிறீர்களா என் று உைவினர்கள் நகட்கப் படுவார்கள்
கவன் டிநலட்டர் சிகிச்மச
ஆக்கிரமிப் பு இல் லாதது மூச்சுக்குழலுக்குள் குழாய் கசருகுதல்
16. தனிமம வோர்டில் அனுமதி – ஏன்?
 ஒரு பர் நகாவிட்19 ந ர்ைமையாக இரு ்தால் (பாசிடிவ் ), அவர் சுகாதாரப்

பணியாளர்கள் , பிை ந ாயாளிகள் ைை் றுை் குடுை் ப உறுப் பினர்களுக்கு
கதாை் றுந ாமயப் பரப் ப முடியுை் . எனநவ இ ்த அபாயத்மதக் குமைக்க அவர்கள்
தனிமைப் படுத்தப் பட்ட வார்டில் இருக்க நவண்டுை் .
 நகாவிட்19 நசாதமன முடிவு எதிர்ைமையாக (க கடிவ் ) இரு ் தால் , ந ாயாளி
வழக்கைான வார்டுக்கு ைாை் ைப் படுவார்..
 நகாவிட்19 நசாதமன ந ர்ைமையானதாக (பாசிடிவ் ) இரு ்தால் , அவர்கள் நைை் படுை்
வமர நசாதமன எதிர்ைமையாக (க கடிவ் ) ைாறுை் வமர ந ாயாளி தனிமை வார்டில்
இருப் பார்.
17. வநோயோளி குணமமடய வோய் ப் புகள் என்ன?
 நகாவிட்19 ந ாய் த்கதாை் று சுைார் 97% ந ாயாளிகளுக்கு குணைாகுை் .

 நலசான அறிகுறிகமளக் ககாண்ட ந ாயாளிகள் (காய் ச்சல் , இருைல் அல் லது
கதாண்மட புண்) எளிதில் குணைமடகிைார்கள் .
 ஆக்ஸிஜன் நதமவப் படுை் ைை் றுை் ஐ.சி.யுவில் அனுைதிக்கப் பட்ட ந ாயாளிகளுக்கு,
கடுமையான ந ாய் ைை் றுை் உயிருக்கு அதிக ஆபத்து உள் ளது.
 சிகிச்மசயளிக்குை் ைருத்துவர் ந ாயாளி ைை் றுை் உைவினர்களிடை் நபசுை் நபாது
ந ாயாளி குணைமடவதை் கான வாய் ப் புகமள விளக்குவார்.
18. ஒரு வநோயோளியின் உறவினர்களுக் கு வநோயின் அபோயங் கள் என்ன?
 நகாவிட்19 நசாதமன எதிர்ைமையாக (க கடிவ் ) இரு ்தால் , எ ்த குடுை் ப

உறுப் பினர்களுக்குை் எ ்த ஆபத்துை் இல் மல.
 நகாவிட்19 நசாதமன ந ர்ைமையானதாக (பாசிடிவ் ), இரு ்தால் , ந ாயாளியுடன்
கதாடர்பு ககாண்ட குடுை் ப உறுப் பினர்கள் வீட்டிநலநய தங் கமளத்
தனிமைப் படுத்திக் ககாள் ள (தனிமைப் படுத்த) அறிவுறுத்தபடுவார்கள்

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 அவர்கள் ைருத்துவைமனயின் வளாகத்தில் தங் க அனுைதிக்கப் பட ைாட்டார்கள் .
உறவினர்கள் பின்பற் ற கடுமமயோக அறிவுறுத்துகின்ற நடவடிக் மககள் :

o முகமூடி அணியுங் கள்
o ீ ங் கள் ைை் றுை் உங் கமளச் சுை் றியுள் ளவர்கள் , இருைல் அல் லது துை் முை் நபாது
உங் கள் வமள ்த முழங் மக அல் லது ஒரு திசு காகிதத்தால் உங் கள் வாய் ைை் றுை்
மூக்மக மூடுவமத உறுதிப் படுத்திக் ககாள் ளுங் கள் . பின் னர் பயன் படுத்தப் பட்ட
திசு காகிதத்மத உடனடியாக அப் புைப் படுத்துங் கள் .
o ைை் ை குடுை் ப உறுப் பினர்களுடன் க ருங் கிய கதாடர்மபக் குமைத்தல் .
o உங் களுக்குை் இருைல் அல் லது துை் முை் எவருக்குை் இமடயில் குமை ்தது 1 மீட்டர் (3
அடி) தூரத்மத பராைரிக்கவுை் .
o நசாப் பு ைை் றுை் தண்ணீர ் அல் லது ஆல் கஹால் அடிப் பமடயிலான மக-துமடப் பால்
உங் கள் மககமள தவைாைல் முழுமையாக சுத்தை் கசய் யுங் கள்
o உங் கள் கண்கள் , மூக்கு ைை் றுை் வாமயத் கதாடுவமதத் தவிர்க்கவுை் .
o 14 ாட்களுக்கு வீட்டின் வளாகத்மத விட்டு கவளிநயை நவண்டாை் .
o நதமவயை் ை பார்மவயாளர்கள் வருவமத தவிர்க்கவுை் .
o உங் களுக்கு இருைல் , காய் ச்சல் அல் லது சுவாசக் நகாளாறு ஏை் பட்டால் ீ ங் கள்
ைருத்துவைமனக்கு வர நவண்டுை்
o முடி ்தால் வீட்டில் ஒரு தனி அமையில் தங் கவுை் .
o முடி ்தால் தனி குளியலமைகள் / கழிப் பமைகமளப் பயன் படுத்துங் கள் .
o தட்டுகள் , கரண்டி, கண்ணாடி ஆகியவை் மை பகிர் ்து ககாள் ள நவண்டாை் .
துண்டுகள் ைை் றுை் கபட்ஷீட்கமளப் பகிர நவண்டாை் .
o உங் கள் துணிகமளத் தனியாகக் கழுவுங் கள் .
19. வநோயோளியுடன் சந் திப் பு
 ந ாயாளிமய தனிமைப் படுத்தப் பட்ட வார்டில் அல் லது ஐ.சி.யுவில்

அனுைதிக்குை் நபாது அவர்கமள ச ்திக்க உைவினர்கள் அனுைதிக்கப் பட ைாட்டார்கள் .
 இது குடுை் ப உறுப் பினர்களுக்கு கதாை் று ஏை் படுை் அபாயத்மதக் குமைப் பதாகுை் .
 இருப் பினுை் , ந ாயாளியின் ிமல சரியாக இருக்குை் நபாது ந ாயாளி
உைவினர்களுடன் கதாமலநபசியில் நபச அனுைதிக்கப் படுவார்.
20. மருத்துவர்களுடன் ததோடர்புதகோள் வது
 உைவினர்கள் ைருத்துவைமனயில் தங் கியிரு ்தால் , ைருத்துவர்கள் அவர்கமள ந ரில்

ச ்திப் பார்கள் அல் லது ஒரு ாமளக்கு ஒரு முமையாவது கதாமலநபசியில்
நபசுவார்கள் .
 உைவினர்கள் ைருத்துவைமனயில் தங் கவில் மல என் ைால் , ைருத்துவர்கள் ஒரு
ாமளக்கு ஒரு முமையாவது கதாமலநபசியில் நபசுவார்கள் .
 ைருத்துவ ிமல, சிகிச்மசயின் முன் நனை் ைை் , கசய் யப் படுை் நசாதமனகள் ைை் றுை்
மீட்குை் கசயல் முமை குறித்து ைருத்துவர்கள் விளக்குவார்கள் .
 ஏநதனுை் முடிவுகள் எடுக்கப் பட நவண்டுைானால் , ைருத்துவர்கள் ிமலமைமய
விளக்கி உைவினர்களுடன் கல ்துமரயாடுவார்கள்
 ந ாயாளியின் ிமல நைாசைானால் சிகிச்மச அளிக்குை் ைருத்துவ குழுமவ
நசர் ்தவர்கள் உடனடியாக உைவினர்கமள கதாடர்பு ககாள் வார்கள் .
 சிகிச்மச முடி ்து ந ாயாளி ைருத்துவைமனயில் இரு ்து வீடு கசல் லுை் நபாது,
வீட்டிை் கு கசன் ை பிைகு என் ன கசய் வது என் பது குறித்த கதளிவான அறிவுறுத்தல் கள்
வழங் கப் படுை் .

88

Vellore
ADVICE FOR PATIENTS GETTING DISCHARGED AFTER

CORONAVIRUS (COVID19) INFECTION
We are happy that you are getting discharged from the hospital and going home. Please follow these
instructions in order to ensure your continued good health and reduce the risk of transmitting this
infection to your family members
PRECAUTIONS WHILE LEAVING THE HOSPITAL

When leaving the hospital, you will be asked to wear a mask. You should wear it until you get home.
PRECAUTIONS AT HOME
The virus is spread easily through tiny droplets when you cough or sneeze or talk loudly. You should
take the following steps to help prevent the disease from spreading to people in your home and
community
1. Self-isolate at home:
Separate yourself from other people and animals in your home for at least 7 days after your
discharge
 As much as you can, stay in a specific room and away from other people in your home. You
should also use a separate bathroom, if available.
 Avoid sharing personal household items like dishes, drinking glasses, cups, eating utensils,
towels, toothpaste, or bedding with other people or pets in your home. After using these items,
they should be washed well with soap and water.
 Do not handle pets or other animals while sick.
 Do not go outside your home or use public transport (e.g. Buses and taxis) during this period
2. Clean and disinfect:
Clean all “high-touch” surfaces and laundry every day.

 High-touch surfaces include table tops, doorknobs, switches, bathroom fixtures, toilets, phones,
keyboards of computers and cell phones
 Clean any surfaces that may have your body fluids on them. Use a household cleaning liquid
or soap for this and follow the label instructions for safe and effective use.
 Remove and wash clothes or bedding that have your body fluids on them and then wash your
hands right away

89
3. Help stop the spread: Clean your hands often.
 Wash your hands with soap and water for at least 20 seconds OR use an alcohol-based hand
sanitizer that contains at least 60% alcohol, covering all surfaces of your hands and rubbing
them together until they feel dry.
 Wash your hands after blowing your nose, coughing, or sneezing; going to the bathroom, and
before eating or preparing food.
 Avoid touching your eyes, nose, and mouth with unwashed hands.
4. Cover your coughs and sneezes.
 Cover your mouth and nose with a kerchief/tissue paper when you cough or sneeze.
 Throw used tissue paper in a lined trash can; clean your hands right away.
 Wash kerchiefs with soap and water and dry well, preferably in sunlight.
5. Wear a facemask
 You should wear a facemask at home throughout the period of home isolation
 After the period of home isolation you should wear a mask whenever you leave the house for
any purpose
 Ensure that the mask covers both your nose and mouth at all times
6. Inform your close contacts to self-isolate and monitor for symptoms
 People that you live with should self-isolate for 14 days AFTER your self-isolation period ends.
 Your close contacts should self-monitor for symptoms by checking their temperature twice a
day and watching for fever, sore throat, cough, diarrhea or shortness of breath. They should
come to the hospital if they develop symptoms of COVID-19.
 They should also clean hands often and avoid touching eyes, nose, and mouth with unwashed
hands.
 They should wear a mask at all times during their self-isolation period, and whenever they leave
the house after the self-isolation period
 During this time arrange for all essential supplies to be delivered to your home so that you and
your close contacts do not need to step out
7. What are the danger signs I should watch for?

 If your breathing is getting worse (harder or faster than before or you feel like you are getting
less air), if you develop chest tightness or pain, if you find your fingers, toes or lips turning
blue or if you find yourself becoming confused and disoriented, come to the hospital
immediately.
8. When should I come for my routine check-up?
 You will be given an appointment to visit the outpatient clinic 2 and 4 weeks after your
discharge from the hospital

90
OT TO NOT TO BE MINISTERED UNTO BUT TO MINISTER

வவலூர்
வகோவிட் 1 9 ததோற் று வநோய் க் கு சிகிச்ம ச தபற் று

வீடு திரும் பும் வநோயோளிக் க ோன ஆவலோசமன மற் றும் குறிப் புகள்
ீ ங் கள் ைருத்துவைமனயில் இரு ் து வீட்டிை் குச் கசல் வதில் ாங் கள்

ைகிழ் சசி
் யமடகிநைாை் . உங் கள் கதாடர்ச்சியான ல் ல ஆநராக்கியத்மத
உறுதிப் படுத்தவுை் , உங் கள் குடுை் ப உறுப் பினர்களுக்கு இ ்த ந ாய் த்கதாை் று பரவுை்
அபாயத்மத குமைக்கவுை் இ ்த வழிமுமைகமளப் பின் பை் ைவுை்
மருத்துவமமனயிலிருந் து தவளிவயறும் வபோது

ைருத்துவைமனயிலிரு ்து கசல் லுை் நபாது முக கவசை் (ைாஸ்க்)அணியுைாறு
நகட்கப் படுவீர்கள் . ீ ங் கள் வீட்டிை் கு வருை் வமர அமத அணிய நவண்டுை் .
வீட்டில் முன்தனச்சரிக்மககள்
ீ ங் கள் இருைல் அல் லது துை் முை் நபாது அல் லது சத்தைாக நபசுை் நபாது சிறிய துளிகளால்
மவரஸ் எளிதில் பரவுகிைது. உங் கள் வீடு ைை் றுை் சமூகத்தில் உள் ளவர்களுக்கு ந ாய்
பரவாைல் தடுக்க கீழ் கண்ட டவடிக்மககமள ீ ங் கள் எடுக்க நவண்டுை்
1. வீட்டில் சுய தனிமம:

 ைருத்துவைமனயில் இரு ்து வீடு திருை் பியபின் குமை ்தது 7 ாட்களுக்கு உங் கள்
வீட்டிலுள் ள ைை் ைவர்களிடமிரு ்துை் விலங் குகளிடமிரு ்துை் விலகி இருங் கள்
 உங் களால் முடி ்தவமர, ஒரு குறிப் பிட்ட அமையில் தங் கியிரு ் து, உங் கள் வீட்டிலுள் ள
ைை் ைவர்களிடமிரு ்து விலகி இருங் கள் . முடி ்தால் , ீ ங் கள் ஒரு தனி குளியலமைமய
பயன் படுத்த நவண்டுை் .
 உணவு உண்ண ைை் றுை் பருக பயன் படுத்துை் பாத்திரங் கள் , துண்டுகள் , பை் பமச அல் லது
படுக்மக நபான் ை வீட்டுப் கபாருட்கமள உங் கள் வீட்டில் உள் ள ைை் ைவர்களுடன் அல் லது
கசல் லப் பிராணிகளுடன் பகிர் ்து ககாள் வமதத் தவிர்க்கவுை் . இ ்த கபாருட்கமளப்
பயன் படுத்திய பிைகு, அவை் மை நசாப் பு ைை் றுை் தண்ணீரில் ன் கு கழுவ நவண்டுை் .
 ந ாய் வாய் ப் பட்டிருக்குை் நபாது கசல் லப் பிராணிகமளநயா அல் லது பிை
விலங் குகமளநயா மகயாள நவண்டாை் .
 இ ்த காலகட்டத்தில் உங் கள் வீட்டிை் கு கவளிநய கசல் ல நவண்டாை் . கபாது
நபாக்குவரத்மத (நபரு ்துகள் ைை் றுை் டாக்சிகள் ) பயன் படுத்த நவண்டாை்
2. சுத்தம் மற் றும் கிருமி நீ க்கம் :

 ஒவ் கவாரு ாளுை் அமனத்து “உயர்-கதாடு” (அதிகைாக கதாடுை் ) நைை் பரப் புகமளயுை்
துணிைணிகமளயுை் அடிக்கடி சுத்தை் கசய் யுங் கள் .
 உயர்-கதாடு (அதிகைாக கதாடுை் ) நைை் பரப் புகமள (நைமஜ, ாை் காலி, கதவின் மகபிடிகள் ,
ஸ்விட்ச,் கதாமலநபசி ைை் றுை் மகநபசிகள் ) அடிக்கடி சுத்தை் கசய் யுங் கள் .

91
 உங் கள் உடல் திரவங் கமளக் (எச்சில் , சளி, சிறு ீ ர்) ககாண்டிருக்குை் எ ்த
நைை் பரப் புகமளயுை் சுத்தை் கசய் யுங் கள் . இதை் காக வீட்டு சுத்தை் கசய் யுை் திரவை் அல் லது
நசாப் மபப் பயன் படுத்துங் கள் . பாதுகாப் பான ைை் றுை் பயனுள் ள பயன் பாட்டிை் கான
வழிமுமைகமளப் பின் பை் ைவுை் .
 உங் கள் உடல் திரவங் கமளக் ககாண்டிருக்குை் (எச்சில் , சளி, சிறு ீ ர்) துணிகமள அல் லது
படுக்மககமள அகை் றி கழுவவுை் ,
 பின் னர் உங் கள் மககமள கழுவவுை்
3. கிருமி பரவுவமத தடுக்க உதவுங் கள் ; அடிக்கடி மககமள சுத்தம் தசய் யுங் கள்
 குமை ்தது 20 வி ாடிகளுக்கு உங் கள் மககமள நசாப் பு ைை் றுை் தண்ணீரில்
கழுவவுை் அல் லது குமை ்தது 60% ஆல் கஹால் ககாண்டிருக்குை் ஆல் கஹால்
அடிப் பமடயிலான மக சுத்திகரிப் பா மனப் பயன் படுத்தவுை் . உங் கள் மககளின்
அமனத்து நைை் பரப் புகமளயுை் மூடி, அமவ வைண்டு நபாகுை் வமர ஒன் ைாக
நதய் க்கவுை் .
 மூக்கு சி ்துதல் , இருைல் அல் லது துை் ைலுக்குப் பிைகு; அல் லது கழிப் பமைக்குச்
கசல் வதை் கு முன் புை் உணவு அரு ்துை் முன் புை் மககமள கழுவவுை்
 கழுவப் படாத மககளால் உங் கள் கண்கள் , மூக்கு ைை் றுை் வாமயத் கதாடுவமதத்
தவிர்க்கவுை் .
4. உங் கள் இருமல் மற் றும் தும் மல் .

 ீ ங் கள் இருமுை் நபாது அல் லது துை் முை் நபாது உங் கள் வாய் ைை் றுை் மூக்மக ஒரு
மககுட்மட / திசு காகிதத்துடன் மூட நவண்டுை் .
 பயன் படுத்தப் பட்ட திசு காகிதத்மத ஒரு குப் மபத் கதாட்டியில் எறியுங் கள் ; உடநன
உங் கள் மககமள சுத்தை் கசய் யுங் கள் .
 மககுட்மடகமள நசாப் பு ைை் றுை் தண்ணீரில் கழுவி ன் கு உலர மவக்கவுை் ,
முன் னுரிமை சூரிய ஒளியில் .
5. முககவசம் வபஸ்மோஸ்க் அணியுங் கள்

 வீட்டில் தனிமைப் படுத்தப் பட்ட காலை் முழுவதுை் ீ ங் கள் வீட்டில் முககவசை் (ைாஸ்க்)
அணிய நவண்டுை்
 வீட்டு தனிமைப் படுத்தப் பட்ட காலத்திை் குப் பிைகு ீ ங் கள் எ ்த ந ாக்கத்திை் காகவுை்
வீட்மட விட்டு கவளிநயறுை் நபாகதல் லாை் முககவசை் (ைாஸ்க் ) அணிய நவண்டுை்
 முககவசை் (ைாஸ்க்) எல் லா ந ரங் களிலுை் உங் கள் மூக்கு ைை் றுை் வாய் இரண்மடயுை்
உள் ளடக்கி இருக்க நவண்டுை்
6.உங் கள் க ருங் கிய கதாடர்புகமள சுயைாக தனிமைப் படுத்தவுை் , அறிகுறிகமளக்

கண்காணிக்கவுை் கதரிவிக்கவுை்
 உங் கள் சுய-தனிமை காலை் முடி ்ததுை் , உங் களுடன் இருப் பவர்கள் 14 ாட்கள்
சுயைாக தனிமைப் படுத்தப் பட நவண்டுை் .
 உங் கள் க ருங் கிய கதாடர்புகள் , தங் களுக்கு காய் ச்சல் , கதாண்மட வலி, இருைல் ,
வயிை் றுப் நபாக்கு அல் லது மூச்சுத் திணைல் நபான் ை ந ாய் அறிகுறிகள் உள் ளனவா
என் று ஒரு ாமளக்கு இரண்டு முமை கண்காணிக்க நவண்டுை் . நகாவிட்19
அறிகுறிகள் நதான் றினால் அவர்கள் ைருத்துவைமனக்கு வர நவண்டுை் .
 அவர்கள் அடிக்கடி மககமள சுத்தை் கசய் ய நவண்டுை் ைை் றுை் கழுவப் படாத
மககளால் கண்கள் , மூக்கு ைை் றுை் வாமயத் கதாடுவமதத் தவிர்க்க நவண்டுை் .

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 அவர்கள் தங் கள் தனிமைப் படுத்தப் பட்ட காலகட்டத்தில் எல் லா ந ரங் களிலுை் ,
ைை் றுை் சுய-தனிமைப் படுத்தப் பட்ட காலத்திை் குப் பிைகு அவர்கள் வீட்மட விட்டு
கவளிநயறுை் நபாகதல் லாை் , முககவசை் (ைாஸ்க்) அணிய நவண்டுை் ,
 இ ்த ந ரத்தில் ீ ங் களுை் உங் கள் க ருங் கிய கதாடர்புகளுை் கவளிநய கசல் ல
நதமவயில் லாத அமனத்து அத்தியாவசிய கபாருட்கமளயுை் உங் கள் வீட்டிை் கு
வழங் க ஏை் பாடு கசய் யுங் கள்
7. நோன் கவனிக்க வவண்டிய வநோய் ஆபத்து அறிகுறிகள் யோமவ?

உங் கள் சுவாசை் நைாசைமட ் து ககாண்டிரு ்தால் (முன் மப விட கடினைாக அல் லது
நவகைாக அல் லது ீ ங் கள் குமை ்த காை் மைப் கபறுவது நபால் உணர் ்தால் ), ீ ங் கள்
ைார்பு இறுக்கை் அல் லது வலிமய உணர் ் தால் உங் கள் விரல் கள் , கால் விரல் கள்
அல் லது உதடுகள் ீல ிைைாக இருப் பமதக் கண்டால் அல் லது ீ ங் கள்
குழப் பைமடவமதக் கண்டால் , உடனடியாக ைருத்துவைமனக்கு வாருங் கள் .
8. எனது வழக்கமோன வசோதமனக்கு நோன் எப் வபோது வர வவண்டும் ?

ீ ங் கள் ைருத்துவைமனயில் இரு ்து கவளிநயை் ைப் பட்ட 2 ைை் றுை் 4 வாரங் களுக்குப் பிைகு
கவளிந ாயாளர் கிளினிக்கிை் க்கு வர (அப் பாய் ன் ட்கைன் ட்) ஏை் பாடு கசய் யபடுை் .

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Vellore
COVID19 DEATH - BEREAVEMENT ADVICE

This information sheet is being provided to you either because your relative who came to us with
COVID19 has passed away, or he/she is critically ill and the treating doctors think that he/she may
not survive. In the vent of such a death, we hope this document will help you understand what all
needs to done thereafter..
It is normal to feel grief when you lose a loved one. However, in the present situation where many
procedures have been put in place to prevent the spread of COVID19, you may find it additionally
difficult to manage the situation. So, if you want some of us to talk to you about this or pray for
you, please let us know.
Please understand that as a hospital, we have to abide by the rules of the government and that these
rules are in place to protect the near and dear ones of the deceased person from the risk of infection.
These are the main points that you need to know as to what happens after the death of a COVID19
patient
1. The dead body will be placed in a body bag and closed by a zip from head to toe.
2. If needed, our staff can open the zip at the head side so that you can see the face. Bathing, kissing,
or hugging the body should not be done.
3. You can decide on whether you prefer the body to be buried or cremated, but the entire process
will be supervised by government officials.
4. The body will be kept in the mortuary till all official formalities are completed and the government
has made arrangements for funeral.
5. Please note that if you wish to transport the body out of Vellore, this would require special
permission from the collector of the district that you wish to take the body to; and this will
additional processing time.
6. When travelling to and from the burial/cremation ground only individuals who live together in
the same house should travel together in the same vehicle.
7. Do not advertise the funeral; avoid crowd gathering
8. It is possible that some of the close family contacts may have the infection without any external
indications (signs) of it and this puts all people attending the funeral at risk of getting the infection.
So, Only a limited number of family members (5-10) will be allowed to participate in the
burial/cremation Any individual who is at high risk of being affected by coronavirus (those aged
> 60 years, those with health problems like diabetes, hypertension, kidney disease, liver disease,
heart disease or taking immunosuppressive medicines) should not attend the funeral

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9. Any family member who has fever with cough/sore throat/diarrhea should not attend the
funeral/burial
10. Everyone attending the funeral must maintain a minimum distance of 1 meter from each other
and are wear masks covering the nose and mouth at all times
11. Religious rituals such as reading from religious scripts, sprinkling holy water and any other last
rites that do not require touching of the body can be done.
12. The cremation/ burial staff and everyone who attended the funeral should wash their hands with
soap and water after the cremation/ burial.
13. If the body has been cremated, the ash can be collected to perform the last rites because it does
not pose any infection risk.
We pray that God gives you the peace and comfort that you need at this difficult time.

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வவலூர்
வகோவிட் 19 இறப் பு ஆவலோசமன மற் றும் குறிப் புகள்
இ ்த தகவல் தாள் உங் களுக்கு தரப் படுை் காரணை்
நகாவிட் 19 சிகிச்மசக்காக வ ்த உங் கள் உைவினர்

 இை ்துவிட்டார் (அல் லது)
 மிக நைாசைான ிமலயில் இருக்கிைார் ைை் றுை் அவருக்கு சிகிச்மச
அளிக்குை் ைருத்துவர்கள் அவர் உயிர் பிமழப்பது கடினை் என்று
கருதுகிைர்கள் .
இ ் ிமலயில் , ஒரு நவமள ைரணை் சை் பவித்தால் , நைை் ககான்டு என்ன

டக்குை் என்று ீ ங் கள் அறியவுை் உங் கமள தயார் கசய் யவுை் இ ்த தகவல்
தாள் உதவுை் என்று கருதுகிநைாை்
ீ ங் கள் ந சிப்பவமர இழக்குை் நபாது வருத்தப்படுவது இயல் பு. இ ்த

ிமலயில் , நகாவிட்19 நைலுை் பரவுவமத தடுக்க பல வழிமுமைகள்
பின்பை் ைபடுவது, உங் களுக்கு இ ்த சூழ் ிமலயில் கடினைாக இருக்கலை் .
எனநவ எங் கள் குழுவிலிருன்து யாராவது உங் களிடை் நபசநவா அல் லது
உங் களுக்காக பிரார்த்தமன கசய் யநவா ீ ங் கள் விருை் பினால் , எங் களுக்கு
கதரியபடுத்துங் கள் ..
ஒரு ைருத்துவைமனயாக, ாங் கள் அரசாங் கத்தின் விதிகமள பின்பை் ை

நவண்டுை் என்பமதயுை் , நைலுை் இை ்த பரின் க ருங் கிய ைை் றுை்
அன்பானவர்கமள ந ாய் த்கதாை் று அபாயத்திலிரு ்து பாதுகாக்க தான்
இ ்த விதிகள் உள் ளன என்பமதயுை் . தயவுகசய் து புரி ்து ககாள் ளுங் கள்
உங் கள் அன்புக்குரியவரின் ைரணை் ஏை் பட்டால் ீ ங் கள் உங் கமள

தயார்படுத்திக் ககாள் ள நவண்டிய முக்கிய ைாை் ைங் கள் இங் நக:
1. இை ்த உடல் ஒரு உடல் மபயில் மூடப்பட்டிருக்குை் , இது தமல முதல் கால்
வமர ஜிப் கசய் யப் படுை் .

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2. உடல் மபயின் முகநூல் ஊழியர்களால் முகத்மதப் பார்க்க உங் கமள

அனுைதிக்க முடியுை் , ஆனால் இை ்த உடலின் குளியல் , முத்தை் ,
கட்டிப்பிடிப்பு நபான்ைமவ அனுைதிக்கப்படாது
3. உடமல அடக்கை் கசய் ய அல் லது தகனை் கசய் ய விருை் புகிறீர்களா
என்பமத ீ ங் கள் தீர்ைானிக்கலாை் , ஆனால் முழு கசயல் முமையுை்
அரசாங் க அதிகாரிகளால் கண்காணிக்கப்படுை் .
4. அமனத்து சை் பிரதாயங் களுை் ிமைவமடயுை் வமர உடமல
சவக்கிடங் கில் மவக்கப்படுை் , உடமல தமலயிடுவதை் கான ஏை் பாடுகமள
அரசாங் கை் கசய் துள் ளது.
5. உடமல நவலூரிலிரு ்து ககாண்டு கசல் ல விருை் பினால் , உடமல எடுத்துச்
கசல் ல விருை் புை் ைாவட்டத்தின் நசகரிப்பாளரிடமிரு ்து இதை் கு சிைப்பு
அனுைதி நதமவப்படுை் என்பமத புரி ்து ககாள் ளுங் கள் , இது
கசயல் முமைமய நைலுை் தாைதப்படுத்துை் .
6. புமதகுழி / தகன மைதானத்திை் குச் கசல் லுை் நபாது ைை் றுை் பயணை்
கசய் யுை் நபாது, ஒநர வீட்டில் ஒன்ைாக வசிக்குை் பர்கள் ைட்டுநை ஒநர
வாகனத்தில் ஒன்ைாகப் பயணிக்க நவண்டுை் என்பமத உறுதிப்படுத்தவுை் .
7. இறுதி சடங் மக விளை் பரப்படுத்த நவண்டாை் ; கூட்டை் கூட்டத்மதத்
தவிர்க்கவுை்
8. கதாை் று அபாயத்மதக் குமைப்பதை் காக ஒரு குறிப்பிட்ட
எண்ணிக்மகயிலான குடுை் ப உறுப்பினர்கள் (5-10) ைட்டுநை அடக்கை் /
தகனை் பார்க்க அனுைதிக்கப்படுவார்கள் , ஏகனனில் க ருங் கிய குடுை் ப
கதாடர்புகள் எதுவுை் இல் லாவிட்டாலுை் கதாை் றுந ாமயக்
ககாண்டிருக்கக்கூடுை் . அ ்த ந ரத்தில் அறிகுறிகள் . இது ைை் ை குடுை் ப
உறுப்பினர்களிமடநய கதாை் று பரவுை் அபாயத்மத அதிகரிக்குை் .
9. ககாநரானா மவரஸிலிரு ்து அதிக ஆபத்தில் இருக்குை் எ ்தகவாரு
குடுை் ப உறுப்பினருை் (60 வயதுமடயவர்கள் , ீ ரிழிவு, உயர் இரத்த அழுத்தை் ,
சிறு ீ ரக ந ாய் , கல் லீரல் ந ாய் , இதய ந ாய் அல் லது ந ாகயதிர்ப்புத்
தடுப்பு ைரு ்துகள் நபான்ை உடல் லப் பிரச்சிமனகள் உள் ளவர்கள் ) இறுதிச்
சடங் கில் கல ்து ககாள் ளக்கூடாது என்பமத உறுதிப்படுத்தவுை் . அடக்கை்
10. இருைல் / கதாண்மட வலி / வயிை் றுப்நபாக்குடன் காய் ச்சல் உள் ள எ ்த
குடுை் ப உறுப்பினருை் இறுதி சடங் கில் / அடக்கை் கசய் யக்கூடாது என்பமத
உறுதிப்படுத்தவுை்
11. இறுதி சடங் கில் கல ்துககாள் பவர்கள் அமனவருை் ஒருவருக்ககாருவர்
குமை ்தபட்சை் 1 மீட்டர் தூரத்மத பராைரிப்பமத உறுதிகசய் து, மூக்கு

97
ைை் றுை் வாமய ைமைக்குை் முகமூடிகமள எல் லா ந ரங் களிலுை் அணி ்து
ககாள் ளுங் கள்
12. ைத எழுத்துக்களிலிரு ்து வாசித்தல் , புனித ீ மரத் கதளித்தல் ைை் றுை்
உடமலத் கதாடத் நதமவயில் லாத நவறு எ ்த இறுதி சடங் குகளுை்
அனுைதிக்கப்படுகின்ைன.
13. தகனை் / அடக்கை் ஊழியர்கள் ைை் றுை் குடுை் ப உறுப்பினர்கள் தகனை் /
அடக்கை் கசய் தபின் நசாப்பு ைை் றுை் தண்ணீரில் மககமள கழுவ நவண்டுை் .
14. உடல் தகனை் கசய் யப்பட்டிரு ்தால் , சாை் பல் எ ்தகவாரு கதாை் று
அபாயத்மதயுை் ஏை் படுத்தாததால் , இறுதி சடங் குகமளச் கசய் ய
நசகரிக்கப்படலாை்
இ ்த கடினைான ந ரத்தில் உங் களுக்கு நதமவயான அமைதிமயயுை்

ஆறுதமலயுை் கடவுள் தருவார் என்று ாங் கள் ை் புகிநைாை் .

CMC Handbook For Management of COVID19

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CMC Handbook For Management of COVID19

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1

CHRISTIAN MEDICAL COLLEGE

CMC-Handbook for Clinical Management of COVID19

"You will not only be curing diseases, but will also be

The practice of medicine affords scope for the exercise of the

An excerpt from Aunt Ida’s speech at the first graduation in 1922

CMC-Handbook for Clinical Management of COVID19

CMC-Handbook for Clinical Management of COVID19

INFECTION PREVENTION AND CONTROL

CMC-Handbook for Clinical Management of COVID19

TRANSMISSION RISK TO HEALTH CARE WORKERS IN THE CONTEXT OF

PROCEDURES WITH HIGH RISK OF TRANSMISSION include:

WHAT IS THE CURRENT EVIDENCE?

1. Nosocomial transmission from patients to staff is very low in reported literature.

PRECAUTIONS TO BE FOLLOWED TO MINIMIZE RISK OF INFECTION

While inside COVID treatment areas

1. Bring only what is absolutely necessary to work.

CMC-Handbook for Clinical Management of COVID19

While moving elsewhere in the hospital

While in the Community

1. Inform your supervisor and do not come to the workplace.

CMC-Handbook for Clinical Management of COVID19

APPROPRIATE USE AND RE-USE OF PPE

What PPE is recommended

Area Procedure PPE Re-use policy for N95

How PPE should be donned and doffed

CMC-Handbook for Clinical Management of COVID19

ADMINISTRATION, CHECKLISTS, TEMPLATES

CMC-Handbook for Clinical Management of COVID19

JOB DESCRIPTIONS OF TEAM MEMBERS

- Troubleshooting the junior consultants on the floor

3. COVID ward consultants

4. Level 1 admissions consultant

CMC-Handbook for Clinical Management of COVID19

6. Registrars and interns

The responsibilities include

CMC-Handbook for Clinical Management of COVID19

WORK ROUTINE IN COVID WARDS

S.No Activity Who Remarks

CMC-Handbook for Clinical Management of COVID19

Frequently asked questions regarding patient care

Routine blood investigations many be done by leaving

An investigation should not be ordered unless it is

You may leave your name and employment number in

CMC-Handbook for Clinical Management of COVID19

Frequently asked questions on the movement and safety of healthcare workers

CMC-Handbook for Clinical Management of COVID19

PATIENT TRANSFER CHECKLIST

TRANSFER WITHIN HOSPITAL

CMC-Handbook for Clinical Management of COVID19

HISTORY AND EXAMINATION TEMPLATE

Sore throat: Yes No Duration: _____days

Cough: Yes No Duration: _____days Sputum: No Yes Colour: __________

Rhinorrhea: Yes No Duration: _____days

Breathlessness: Yes No Duration: _____days

Diarrhoea: Yes No Duration: _____days

Episodes per day:______

Vomiting: Yes No Duration: _____days

Episodes per day:______

Anosmia: Yes No Duration: _____days

Ageusia: Yes No Duration: _____days

Any travel in the last 2 weeks: Yes No If yes, where? ___________________________

Cough: Yes No Duration: _days Sputum: No Yes Colour: ______