COVID-

19 Made
Easy

SLIDES MODIFIED
FROM DR LIM KC
Outline
1. Basics of COVID-19

2. Clinical Management of COVID-19 (Diagnosis and Treatment)

3. Patient Monitoring

4. Infection Control

5. Some other ward rules

1. Basics of COVID-19
Mode of transmission
• Primarily through droplet transmission

• Contact transmission – shaking hands, contaminated surfaces

“There is no evidence of efficient spread (i.e., routine, rapid spread) to people far
away or who enter a space hours after an infectious person was there.”

• Airborne transmission of SARS-CoV-2 can occur under special circumstances:

• Enclosed spaces
• Prolonged exposure to respiratory particles, often generated with expiratory exertion
(e.g., shouting, singing, exercising).
• Inadequate ventilation or air handling that allowed a build-up of suspended small
respiratory droplets and particles.
https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html
Updated Oct. 5, 2020
 COVID-19 Incubation: Infection to Illness Onset
• Among 10 confirmed cases in Wuhan, Estimated Incubation Period Distribution[1]
Hubei province, China[1]
0.25
• Mean incubation: 5.2 days
(95% CI: 4.1-7.0) 0.20

Relative Frequency
• Among 181 confirmed SARS-CoV-2
0.15
infections occurring outside of Hubei
province[2] 0.10
• Median incubation: 5.1 days
(95% CI: 4.5-5.8) 0.05
• Symptom onset by Day 11.5 of
0
infection in 97.5% of persons 0 7 14 21
Days From Infection to Symptom Onset

1. Li. NEJM. 2020;382:1199. 2. Lauer. Ann Intern Med. 2020;172:577. Slide credit: clinicaloptions.com
COVID-19 Symptoms
• Fever or chills
Respiratory symptoms
• Cough
• Shortness of breath or difficulty breathing
• Fatigue Body ache, fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell Loss of taste and smell
• Sore throat
• Congestion or runny nose
GI symptoms
• Nausea or vomiting
• Diarrhoea
Clinical categories
Clinical stage
1 Asymptomatic
2 Symptomatic, No Pneumonia MILD

3 Symptomatic, Pneumonia
4 Symptomatic, Pneumonia, Requiring supplemental oxygen
SEVERE
5 Critically ill with multiorgan involvement
 Severe disease
WHO
Risk factors
• Age > 50
• Chronic kidney disease
• History of hypertension
• History of cardiovascular
• disease
• Obesity (BMI ≥ 30 kg/m2 )
• Pre-existing pulmonary disease
• Diabetes with A1c > 7.6%
• Use of biologics
• History of transplant or other
immunosuppression
• Uncontrolled HIV (viraemic or CD4
<200)
WHEN HOW (to predict)
Warning signs
Clinical
 Persistent or new onset fever
Day 5 – Day 10 of illness  Persistent symptoms - Lethargy/ anorexia/ cough
 Respiratory compromise
o Exertional dyspnoea
o Respiratory rate more than 25
o SpO2 room air <95%
Laboratory
 A rising CRP value or a single CRP value of ≥50mg/l
 Dropping Absolute lymphocyte count (ALC),
Radiological
 Features of Pneumonia; multi- lobular involvement
or rapidly worsening chest X-ray

1 2 3 4 5 6 7 8 9 10 11 12 13 14
50%

32%
3.5%

14%
8%
“Skill in medicine consists in an eminent degree in timing remedies“, Benjamin Rush 1746-1813
2. Clinical management of
COVID-19
Diagnosis
Treatment
Diagnostic tests available
• RTK Antigen

• RT-PCR

• Rapid PCR test, e.g. GeneXpert

Diagnostic tests available
• RTK Antigen
• Sabah: Positive Predictive Value (PPV) 84%
Diagnostic tests available
• RT-PCR
• Confirmation test for COVID-19
• Take 6 to 8 hours for a completion of test; longer if no in-house facility
• Problem in Sabah: Sending to QE Hospital > delay in diagnosis > delay in
appropriate treatment, isolation, contact tracing

• Rapid PCR tests

• Example: GeneXpert
• Qualitative PCR test
• Results within 1 – 4 hours
• Indications: when urgent diagnosis is required
Suggested protocol on deciding diagnostic tests
NPS Training
NPS Video
Treatment
 Favipravir
Steroids
Steroids - ?Higher dose
Anticoagulants
?Tocilizumab
Favipravir Anticoagulants

“Skill in medicine consists in an eminent degree in timing remedies“, Benjamin Rush 1746-1813
Favipiravir
• Indications
• High risk patients (age >50, co-morbid), category 3, < 7 days of illness (i.e. in
viraemic phase)

• Category 3 patients with warning criteria, < 7 days of illness

Warning signs
Clinical
 Persistent or new onset fever
 Persistent symptoms - Lethargy/ anorexia/ cough
 Exertional dyspnoea or hypoxia
Laboratory
 A rising CRP value or a single CRP value of ≥50mg/l
 Dropping Absolute lymphocyte count (ALC)
Radiological
• multi- lobular involvement or rapidly worsening chest X-ray

• Category 4 and 5 patients, < 7 days of illness

 Favipiravir
Drug Dose & Duration Comments
Teratogenic effect; Contraindicated for women
Favipiravir 1800mg bd for 1 day then 800mg bd of childbearing potential and men whose
5 days – 10 days partner is of childbearing potential.

Avoid if GFR <30ml/min

Liver enzymes > 10 ULN
Drug Dose Duration
Dexamethasone 6mg OD Usually 5 – 10 days

*consider higher dose (equivalent *considering tapering steroid

dose of methylprednisolone 1-2 dose over a few weeks in severe
mg/kg/day) if requiring high oxygen hyperinflammatory cases
support, or if no improvement with
above regimen after 24 – 48 hours

Methylprednisolone 1 – 2 mg/kg/day
 Category 4 and 5 patients

High prophylactic dose anti-coagulation

•Full dose anticoagulation
• High •Prophylaxis

Prophylaxis
Full dose anti-coagulation

• eg. Enoxaparin – 1mg/kg

12hrly prophylactic •e.g. Enoxaparin
dose anti- 20-40mg daily
• Confirmed VTE
• Suspect PE - sudden coagulation depending on
unexplained deterioration • e.g. Enoxaparin - renal function
in oxygenation or
hemodynamic instability, 0.5mg/kg 12hrly
acute cor pulmonale
• Clotting of vascular devices • All patients
(eg, venous, arterial • All ICU patients requiring
devices, and hemodialysis
devices).
• ? Based on supplemental
increased D- oxygen
dimers -
 Take consent before starting
treatment

• Therapy is not proven

• These are not experimental drugs but

medications that are well researched and
used to treat other diseases

• Good evidence that the antivirals are

effective in improving symptoms and some
to clear the virus
Category 4 patients : enforce the following rules
• Patient need to be completely rest in bed

• Self proning

• Urinal for men and commode for women

• Effectively manage the diarrhea (loperamide adequately); lessen the

need to go to toilet.

• Portable O2 whenever need to go to toilet if possible

Prone
position
actually
helps!
Discharge
criteria
Discharge
criteria
3. Patient monitoring
 H Sg Buloh
Morning Passover is compulsory
Specialist/Senior MO
Post call team
Morning team

Identify patients that require special attention.

Understand which patient is in critical phase, which

patient has warning signs before seeing the patient.

Also helps to plan additional blood taking

H Tawau
 Review rules
Asymptomatic Patients Pneumonia with no Pneumonia with
and those with mild hypoxia Critically Ill patients
hypoxia
URTI/ No pneumonia
• Daily review • Daily review • Minimum 8hrly review. • Reviewed By ICU
• Specialist/Senior MO to do • If warning signs • Specialist review at • Specialist review at
quick table rounds at AM present, PM review
& PM least daily least daily
• If deterioration in vitals • If deterioration in vitals
• On call MO review
patients meant for
immediately inform immediately inform
stepdown or discharge specialists specialists

• If first week of illness the night

review can be phone call by the
attending MO asking for emerging
symptoms*.

* Emerging symptoms are fever, cough, exertional dyspnoea or

hypoxia
 Investigation rules
Symptomatic
Pneumonia with no Pneumonia needing
patients without Critically Ill patients
O2 support O2
pneumonia
• Baseline bloods* • Baseline bloods* • Daily bloods including • Daily bloods
• CXR on admission • CXR on admission D-dimer including D-dimer
• Repeat bloods and CXR • If CRP > 50 repeat daily • CXR on admission,
48-72 hours later if
• Cardiac enzymes
persistent cough or fever until improvement repeat if any worsening and ECG, repeat as
• Repeat bloods and CXR oxygenation indicated
48-72 hours later if • ECG baseline and
• CXR on admission,
persistent cough or repeat as indicated
fever • Watch out for bacterial repeat if any
• Repeat bloods and CXR pneumonia worsening
if patient develops oxygenation
exertional dyspnoea or • Watch out for
hypoxia bacterial
pneumonia

* Baseline bloods: FBC with differential count / RP/LFT/CRP to be taken at night review if planned for the next day
COVID-19 review sheet
Risk stratification of patients- ward
admission vs PKRC
PKRC admissions of low risk PKRC admissions of higher risk
patients patients

• Age <50 years old • <50 years old with stable

comorbids
• No comorbids such as DM, HPT,
obesity, chronic pulmonary • 50-70 years old with no
diseases such as asthma, COPD comorbids
• ADL independent
• Not pregnant
• Stable vitals signs with no
warning signs
Readmission after COVID-19 infection
The Lancet Infectious disease: What reinfections mean for COVID-19
Published:October 12, 2020DOI:https://doi.org/10.1016/S1473-3099(20)30783-0
4. Infection Control
REMINDER

 Check everyone’s
temperature 🤒 , report
Keep 6 feet away from
if any member has others
fever. (>=37.5) , each Avoid mass gatherings
and hanging out together
ward should have
thermometer for staff.
COVID-19: Zones
GREEN ZONES YELLOW RED ZONES
ZONES
On call rooms Patient areas
Changing Nurse counter including
rooms toilet
Prayer rooms
Staff toilet
Pantry
Administrative
areas
Cafeteria
PPE based on Zones

ZON MERAH ZON KUNING ZON HIJAU

PPE Training
 EMERGENCY DEPARTMENT Ministry of Health
Malaysia

SETTING: SPECIMEN COLLECTION AREA

TARGET: HEALTHCARE WORKER
ACTIVITY TYPE OF PPE

Performing oropharyngeal or 1) N95 mask

nasopharyngeal swab 2) Gloves*
3) Isolation Gown (fluid-repellent
long-sleeved gown)
4) Plastic apron*
5) Eye protection (face
shield/goggles)
6) Head cover

• It is sufficient to change gloves * Boot cover / shoe cover (ONLY

and plastic apron between when anticipating spillage and
patients vomiting)
(if you are not touching the
patient)

Any soiled/wet protective

equipment should be changed

48
IN-PATIENT FACILITY Ministry of Health
Malaysia

SETTING: PATIENT ROOM

(PUI/CONFIRMED COVID-19)
TARGET: HEALTHCARE WORKER
ACTIVITY TYPE OF PPE

Providing care to PUI/confirmed 1) Surgical mask

COVID-19 patients who are not 2) Isolation Gown (fluid-repellent
intubated and able to wear surgical long-sleeved gown)
mask 3) Gloves
4) Eye Protection (face
shield/goggles)

* Boot cover / shoe cover (ONLY

when anticipating spillage and
vomiting)

49
IN-PATIENT FACILITY Ministry of Health
Malaysia

SETTING: PATIENT ROOM (PUI/CONFIRMED

COVID-19)
TARGET: HEALTHCARE WORKER
ACTIVITY TYPE OF PPE

Providing care to PUI / confirmed 1) N95 mask

COVID-19 patients who are not 2) Isolation Gown (fluid-repellent
intubated but NOT able to wear long-sleeved gown)
surgical mask 3) Gloves
4) Eye Protection (face
Providing care to PUI / confirmed shield/goggles)
COVID-19 patients who are 5) Head cover
ventilated in a closed circuit
* Boot cover / shoe cover (ONLY
when anticipating spillage and
vomiting)

50
IN-PATIENT FACILITY
SETTING: PATIENT ROOM (PUI/CONFIRMED
COVID-19)
TARGET: HEALTHCARE WORKER
ACTIVITY
Performing Aerosol Generating
Procedures (AGP) on PUI /
confirmed COVID-19 patients
With inticipate prolonged exposure
• Intubation, extubation and
related procedures
• Tracheotomy/tracheostomy
procedures
• Manual ventilation
• Suctioning
• Bronchoscopy
• Nebulization
• Others – Refer Guideline
Ministry of Health
Malaysia
TYPE OF PPE
Option 1 (Preferred):
1) PAPR
2) Isolation Gown (fluid-repellent
long-sleeved gown) with plastic
apron / Coverall suit
3) Gloves
4) Eye Protection (face
shield/goggles)*
5) Boot cover / shoe cover
* Depends on type of PAPR
51
IN-PATIENT FACILITY Ministry of Health
Malaysia

SETTING: PATIENT ROOM (PUI/CONFIRMED

COVID-19)
TARGET: HEALTHCARE WORKER
ACTIVITY TYPE OF PPE

Performing Aerosol Generating Option 2:

Procedures (AGP) on PUI / 1) Coverall suit
confirmed COVID-19 patients 2) N95 mask
• Intubation, extubation and 3) Eye Protection (face
related procedures shield/goggles)
• Tracheotomy/tracheostomy 4) Gloves
procedures 5) Boot cover / shoe cover
• Manual ventilation
• Suctioning
• Bronchoscopy
• Nebulization
• Others – Refer Guideline

52
IN-PATIENT FACILITY Ministry of Health
Malaysia

SETTING: PATIENT ROOM (PUI/CONFIRMED

COVID-19)
TARGET: HEALTHCARE WORKER
ACTIVITY TYPE OF PPE

Performing Aerosol Generating Option 3 (if Option 1 & 2 not

Procedures (AGP) on PUI / available):
confirmed COVID-19 patients 1) N95 mask
• Intubation, extubation and 2) Isolation Gown (fluid-repellent
related procedures long-sleeved gown) with plastic
• Tracheotomy/tracheostomy apron
procedures 3) Gloves
• Manual ventilation 4) Eye Protection (face
• Suctioning shield/goggles)
• Bronchoscopy 5) Boot cover / shoe cover
• Nebulization 6) Head cover
• Others – Refer Guideline

53
5. Some other ward rules
PERATURA
N MASUK DENGAN KENALI ZON ANDA AMALKAN HAND
BERPASANGAN / HYGIENE
DENGAN
Sebelum PEMERHATI

memasuki
kawasan
rawatan
pesakit ELAKKAN SENTUH
MUKA & MATA
PERHATIKAN
RAKAN SEKERJA
INGATKAN PESAKIT
MEMAKAI PELITUP
ANDA DONNING & MUKA SEBELUM ANDA
DOFFING MEMASUKI BILIK
TAKE HOME MESSAGES

 Proper NPS technique

 Know who will deteriorate, when will deteriorate, how to detect deterioration early

 Know the treatment modalities available

 Protect yourself and the team

COVID-19
DRIVE

Scan me