Decision No. 468/QD-BYT 2020 Guidance on prevention COVID-19 at medical establishments

  • Summary
  • Content
  • Status
  • Vietnamese
  • Download
Save

Please log in to use this function

Send link to email

Please log in to use this function

Error message
Font size:

ATTRIBUTE

Decision No. 468/QD-BYT dated February 19, 2020 of the Ministry of Health on promulgating the Guidance on prevention and control of acute respiratory infection caused by coronavirus 2019 (COVID-19) at medical examination and treatment establishments
Issuing body: Ministry of HealthEffective date:
Known

Please log in to a subscriber account to use this function.

Don’t have an account? Register here

Official number:468/QD-BYTSigner:Nguyen Truong Son
Type:DecisionExpiry date:
Known

Please log in to a subscriber account to use this function.

Don’t have an account? Register here

Issuing date:19/02/2020Effect status:
Known

Please log in to a subscriber account to use this function.

Don’t have an account? Register here

Fields:Medical - Health

SUMMARY

People having respiratory symptoms should not use hands to cover mouth when coughing

According to the Ministry of Health’s recommendations, all patients or healthcare workers having any respiratory symptom must apply the principles of respiratory hygiene, including: Cover the mouth and nose with tissue when coughing and sneezing, and then discard it into the waste bin. In case no tissue is available, a person may cough onto the upper side of the elbow, not use the hand to cover mouth when coughing.

The patient who has symptoms of coughing or sneezing should wear medical mask when having close contact (<2m) or the healthcare worker examining a patient who has risk of COVID-19 via droplet transmission. Concurrently, wash hands after having contact with excretions. Stand or sit at least 2 meters apart from a COVID-19 confirmed or suspected patient.

Those who do not have respiratory symptoms should avoid gathering and avoid coming to crowded places frequently; keep a distance at least 2 meters off any person having respiratory symptoms (for example: coughing, sneezing), etc. At the same time, do hand hygiene regularly with alcohol-based solution for unsoiled hands or with soap and water for soiled hands.

Those who have respiratory symptoms are recommended to wear medical mask and have to visit hospital as soon as possible in case of fever, cough, dyspnea, etc. and use and manage masks properly, avoiding risks of transmission related to the improper use and discard of mask.

The above-mentioned guidance is issued together with the Decision No. 468/QD-BYT dated February 19, 2020 of the Ministry of Health on promulgating the Guidance on prevention and control of acute respiratory infection caused by coronavirus 2019 (COVID-19) at medical examination and treatment establishments, which takes effect on the signing date.

For more details, click here.
Download files here.
LuatVietnam.vn is the SOLE distributor of English translations of Official Gazette published by the Vietnam News Agency
Effect status: Known

THE MINISTRY OF HEALTH
_________

No468/QD-BYT

THE SOCIALIST REPUBLIC OF VIETNAM

Independence - Freedom - Happiness
______________

Hanoi, 19 February 2020

 
 

DECISION

ON PROMULGATING THE GUIDANCE ON PREVENTION AND CONTROL OF ACUTE RESPIRATORY INFECTION CAUSED BY CORONAVIRUS 2019 (COVID-19) AT MEDICAL EXAMINATION AND TREATMENT ESTABLISHMENTS

____________

MINISTER OF HEAL

Pursuant to the Government's Decree No. 75/2017/ND-CP dated 20/06/2017 defining the functions, tasks, powers and organizational structure of the Ministry of Health;

Considering the request of Director of Medical Administration Department, Ministry of Health,

DECIDES:

 

Article 1.  Promulgated with this Decision the “guidance on prevention and control of acute respiratory infection caused by coronavirus 2019 (covid-19) at medical examination and treatment establishments”.

Article 2. This Decision takes effect from the date of signing

Article 3.  Mr. and Mrs.: Chief of Ministry Office; Chief Inspector of the Ministry; Directors of Departments, Administrations of Ministry of Health; Directors of Departments of Health provinces and centrally-run cities; Directors of Hospitals, Research Institutes with hospital beds under the Ministry of Health; Heads of health agencies of ministries, sectors and heads of relevant units are liable to execute this Decision./.

For the Minister

The Deputy Minister

The National Steering Committee for Prevention of Acute Respiratory Diseases Caused by New Strain of Coronavirus

Nguyen Truong Son

GUIDANCE

ON PREVENTION AND CONTROL OF ACUTE RESPIRATORY INFECTION CAUSED BY CORONAVIRUS 2019 (COVID-19) AT MEDICAL EXAMINATION AND TREATMENT ESTABLISHMENTS

(Attached to the Decision No. 468/QD-BYT dated February 19, 2020 of the Minister of Health)

 

LIST OF ABBREVIATIONS

 

BYT:            Ministry of Health

KBCB:         Examination and Treatment

KSNK:         Infection Control

NB:              Patient

COVID-19:  Acute Respiratory Tract Disease caused by 2019 Coronavirus

NVYT:         Healthcare worker

PHCN:         Personal Protective Equipment (PPE)

PNC:            Standard Precaution

XN:              Test

 

 

CONTENTS

 

List of abbreviation................................................................................................. 8

Definitions............................................................................................................ 11

Strategy, principles and measures to control COVID-19 infection............................. 6

Triage, reception and isolation of COVID-19 confirmed or suspected patients......... 18

Guidance on establishment of isolation ward in a medical facility........................... 24

Use of personal protective equipment..................................................................... 29

Hand hygiene........................................................................................................ 36

Handling of medical instruments............................................................................ 36

Linen handling...................................................................................................... 44

Handling of eating utensils.................................................................................... 46

Cleaning and disinfection of environmental surfaces............................................... 48

Cleaning of transportation vehicles for patients with confirmed or suspected COVID-19   52

Waste treatment.................................................................................................... 54

Collection, packaging and transport specimens ...................................................... 57

Prevention of COVID-19 infection in laboratory.................................................... 65

Treatment of the corpse of COVID-19 confirmed or suspected patients .................. 68

Guidance on prevention of COVID-19 infection over patient families and visitors .. 72

Appendixes .......................................................................................................... 74

References ........................................................................................................... 83

 

 

 

 

 

 

 

DEFINITIONS

 

For the objectives of this Guide, the terms below are construed as follows:

Anteroom: is a small chamber located between the corridor and an isolation chamber, a place to prepare necessary facilities for the isolation room

Healthcare workers: are all employees, employees in medical facilities related to examination, treatment and care of patients (including doctors, nurses, medical technicians, physiotherapists, social workers, psychologists, pharmacists, hygiene workers, etc.)

Contact transmission: is the most common mode of transmission. Contact transmission is divided into 2 groups:

- Transmission through direct contact: microorganisms are transmitted from person to person due to direct contact between the body's tissue or organization (including skin and mucous membranes) with the human skin and mucosa of other, not through an infected medium or intermediary

- Transmission through indirect contact through contaminated things

Transmission by contact is the most common way of spreading microorganisms from a patient to another or a healthcare worker (HCW) to a patient and vice versa.

Healthcare workers who have activities in direct or indirect contact with the patient, with blood or body fluids from the patient are at risk of contracting or spreading the disease in the medical facility.

 Droplet transmission: Droplet transmission occurs when the recipient's mucosa (nasal mucosa, conjunctiva, and less frequently the oral mucosa) encounters droplets of ³5μm pathogen. These particles contain pathogenic microorganisms that are created when coughing, sneezing, talking or performing certain procedures (suction, intubation, chest physiotherapy, cardiopulmonary resuscitation, etc.)

Droplet transmission occurs when there is close contact (<2 meters between a patient and close contacts). Common droplet-borne pathogens are: microorganisms that cause pneumonia, pertussis, diphtheria, influenza, SARS, mumps, Ebola, COVID-19, etc.

Occupational exposure: is the term indicating the direct contact of non-intact mucosa or skin with blood, tissue or body fluids containing sources of infectious diseases or direct contact with chemicals, dangerous rays for the body in the working process of HCWs. Occupational exposure can occur through damaged skin (needle or sharp objects through the skin), contact with mucous membranes (such as eyes, nose or mouth) and contact with non-intact skin.

Standard precaution: is a set of basic preventive measures that apply to all patients in healthcare facilities regardless of diagnosis, infection status and time of care in the principle of considering all blood, secretions and excreted substances (except sweat) risk of disease transmission. Standard precautions should be applied when caring for and treating all patients in the medical facility, regardless of the diagnosis and infection status of the patient.

Transmission-based precaution: are measures to prevent transmission through 3 main routes during medical examination and treatment, including: contact, droplets and air.

Personal Protective Equipment (PPE): are the means to wear to protect HCWs from getting infected when in close contact with patients. Personal protective equipment can also protect the patient from being infected with resident and current microorganisms from HCWs. The most commonly used PPEs include gloves, masks, gowns, waterproof aprons, hats, goggles, face shields and boots or shoe covers, etc. Depending on the risk of transmission of etiology, we can select appropriate PPE.

Hand hygiene: Hand hygiene includes the techniques of hand hygiene with soap and clean water or hand hygiene with alcohol-based solutions or solutions of alcohol and disinfectant.

 Aerosol: are procedures in medical examination and treatment that can make patients' respiratory tract fluid become aerosol particles such as bronchoscopy, endotracheal intubation, tracheostomy, cardiopulmonary resuscitation, non-invasive air ventilation, etc.. These particles are able to survive in air environment.

(Air change per hour – ACH or ACPH):  is a number of times that a total volume of air in a certain area circulating per hour (air change per hour – ACH or ACPH).  If the air or the space in the room is homogeneous or the mixture of them is perfect, the air that changes every hour is a measure of the number of times after which the air in a given space is replaced.

For example: ACH = 12 in a 30 m3 room is the volume of air circulating the room within an hour: 30 m3 x 12 = 360m3.

Medical mask or Surgical mask: The mask used every day by healthcare workers in medical facilities, during surgery or contact with patients who can transmit infection via droplets or respiratory activities. A medical mask is also called surgical mask. In Vietnam, medical mask standards are regulated in TCVN (Vietnam Standard) 8389-2010, including:

- TCVN 8389-1:2010: Normal medical mask.

- TCVN 8389-2:2010: Medical mask for prevention of infection.

- TCVN 8389-3:2010: Medical mask for prevention of chemical toxicity.

In this Guidance, medical mask is construed as a mask meeting TCVN 8389-2 or equivalent.

Respirators mask: In this Guidance, the concept of respirators mask is construed as that meeting the N95 Certification under the standards of National Institute for Occupational Safety and Health  (NIOSH) or the FFP2 standard of European Union (EU) or equivalent (hereinafter collectively called as N95 mask).

 

 

 

 

 

STRATEGY, PRINCIPLES AND MEASURES TO CONTROL COVID-19 INFECTION

 

1. Generalities on Coronavirus and COVID-19

Coronavirus (CoV) is a large family of virus in residing in animals and human. The Coronavirus family consists of 2 types of alpha and 2 types of beta causing diseases in human, with the symptoms from normal flu to more severe cases of diseases. There are about 30% of upper respiratory tract infection caused by the 229E and OC43 originating from the type alpha-CoV and NL63, HKU1 from the type of beta-CoV. The type of beta Corona is the cause of severe acute respiratory disease SARS-CoV and the Middle East Respiratory Syndrome (MERS-CoV), causing severe pneumonia that can lead to death.

Coronavirus has spherical shape with the diameter about 125nm, having spiniform protein on its surface. The virus has 4 major structural proteins which are Spike protein (S), Membrane Glycoprotein (M), Envelope Protein (E) and Nucleocapsid (N). Inside the virus envelope is a single positive fiber, symmetrically spiral. The virus has its RNA of single positive fiber, no segments, about 30 kb.

Figure 1: Coronavirus structure

 

In April 2012 in Saudi Arabia, a patient had to be hospitalized of pneumonia, acute renal injury and died later. This is the first case to be confirmed infected and died of a new strain of virus. Soon after that time, there were many other patients having the same symptoms and the same history to have passed or stayed in Saudi Arabia. The disease-causing agent was then determined a totally new virus strain that caused the acute respiratory disease syndrome and was named Middle East Respiratory Syndrome of Coronavirus (MERS-CoV) and was categorized in Group A of infectious disease. The epidemic caused by MERS-CoV made 2,494 infected case of which 858 died (up to December 2015) in 27 countries, and China was thee place having secondary case due to person-to-person transmission.

          The origin of MERS-CoV has not been thoroughly understood. Some suppositions say that it might originate from bats and transmitted to camels. Infected patients often have the symptoms of acute respiratory disease: fever, cough, severe pneumonia that quickly leads to acute respiratory failure. Additionally, it might cause digestive symptoms such as diarrhea and might cause organ failure, especially renal failure. The death rate is up to 40%. This disease so far has not had specific drug or vaccine.

          At the end of 2019 in China, a pneumonia outbreak, also called Wuhan pneumonia epidemic, emerged. The epidemic began in the middle of December 2019 at Wuhan city when a group of people had pneumonia with unknown reason, mostly associated with those working at Huanan seafood market. Chinese scientists then subdivided a totally new Coronavirus strain (at first WHO marked it as 2019-nCoV, and officially named it COVID-19 later). This strain of virus is found to have the gene sequence resemble at least 70% with SARS-CoV.

The first suspected cases were reported on 31 December 2019 and the initial symptoms appeared on 08 December 2019. The COVID-19 so far has developed very complicatedly. At the end of 18 February 2020, the world has 73,335 infected cases and 1,874 of which died, mostly at the epidemic centre: Wuhan city, Hubei Province, China. All over the world, there have been 28 countries and territories announcing confirmed cases of COVID-19 such as Hong Kong, Macau, the Philippines, Cambodia, Thailand, Singapore, Malaysia, Sri Lanka, India, Nepal, UAE, Japan, Korea, Taiwan, Australia, Germany, France, Spain, Italy, England, Sweden, Finland, Belgium, Russia, USA, Canada, Egypt and Vietnam; people-to-people transmission has been determined.

In Vietnam, up to the date of 18 February 2020, 16 people have been confirmed to be infected with COVID-19. At first, 02 cases of two Chinese were confirmed COVID-19 infection (the father came from Wuhan city and transmitted to his son who is residing and working in Vietnam. Both of them have been recovered and discharged from hospital); 06 Vietnamese returning from Wuhan (05 has recovered and discharged, 01 has recovered, under monitoring); 06 Vietnamese had close contact with COVID-19 positive person (02 has recovered and discharged, 01 has recovered, under monitoring); 01 American coming to Vietnam, transited Wuhan, China; 01 03-month-old baby having close contact with a COVID-19 positive person.

COVID-19 mostly transmits via droplets in close distance with a COVID-19 confirmed patient and via contact. Therefore, wearing medical mask, applying hand hygiene and cleaning environmental surfaces are the utmost important measures in infection prevention. Measures of prevention of infection via air must be applied at areas having aerosol procedures, especially at close distance (< 2 meters) and in tight and badly-ventilated areas.

2. Disease case definitions:

2.1. Suspected cases: including the following cases:

A. The patient has fever and acute respiratory disease AND the disease cannot be explained by other causes AND the patient has the history to come/stay/return from a COVID-19-hit region within 14 days before the symptom onset. OR:

B. The patient has any respiratory symptom AND has at least one of the two following epidemiologic factors emerging within 14 days before the symptom onset:

a. Having close contact (*) with a COVID-19 potential or a confirmed case.

b. Having worked or been present at a medical facility where acute respiratory disease cases or COVID-19 confirmed or potential cases are treated AND having direct contact with these patients.

* Close contact includes:

- Contact at medical facilities, including: providing direct care to COVID-19 confirmed patients; co-working with COVID-19 confirmed healthcare workers; coming to visit the COVID-19 confirmed patient or stay in the same room of a COVID-19 confirmed case.

- Having direct contact in the distance ≤ 1-2 meters with a COVID-19 suspected or confirmed case.

- Living under the same roof with a COVID-19 suspected or confirmed case.

- Working in the same room, learning in the same class, having close domestic activities, etc. with a COVID-19 suspected or confirmed case.

- Having traveled on the same vehicle with a COVID-19 suspected or confirmed case.

2.2. Potential case:

Those cases that are suspected but specimen for testing cannot be collected or the specimen for testing has not been available.

2.3. Confirmed case:

Those cases that are suspected or may be confirmed by real-time RT-PCR test  positive to COVID-19 or by gene sequence decoding technique.

3. COVID-19 Preventive Strategy

The Infection Control Strategy aims at the stop or restriction of COVID-19 spread at medical facilities, including:

- Apply standard precautions to all patients.

- Have early detection, isolate and put the infection source under control.

- Apply standard precautions. It is necessary to prevent droplet transmission and contact transmission. Apply measures to prevent airborne transmission in the areas where aerosol procedures are performed.

- Administrative measures.

- Control the environment and techniques.

4. Preventive Principles

- Apply standard precautions combining with prevention of contact transmission and droplet transmission in examination and care provided to COVID-19 confirmed or suspected patients.

- In the care provided to COVID-19 confirmed or suspected patients with aerosol procedures, measures to prevent airborne transmission must be added.

- Apply respiratory hygiene to all patients having symptoms of respiratory diseases.

- Good control of ventilation, hand hygiene, and sufficient wearing of personal protective equipment are the most important measures to prevent infection to healthcare workers.

5. Measures to control transmission in medical facilities

5.1. Standard precautions

Standard precautions is a set of basic preventive measures that apply to all patients in healthcare facilities regardless of diagnosis, infection status and time of care in the principle of considering all blood, secretions and excreted substances (except sweat) risk of disease transmission. Standard precautions include:

- Hand hygiene must be performed in 5 moments of hand hygiene and with the 6-step hand hygiene technique.

- Use appropriate personal protective equipment subject to the situation as working with blood, body fluids and excretions or expecting to work with blood, body fluids and excretions.

- Execute the rules of respiratory hygiene in coughing or sneezing.

- Prevent injury caused by sharp things during patient care.

- Properly treat utensils used for patient care for re-use.

- Collect, transport, treat soiled linens in a safe manner.

- Disinfect the environment of patient care.

- Treat wastes properly.

- Arrange patients safely.

+ Arrange severe COVID-19 confirmed patients in emergency room, isolation ward or isolation room with sufficient special emergency means.

+ Arrange non-severe COVID-19 confirmed patients in a separate room or a group of the same condition may be arranged in the same room.

+ A COVID-19 positive test (+) patient must not be arranged with COVID-19 suspected patients.

5.2. Transmission-based precautions

5.2.1. Contact Precautions

Contact precautions require the following contents:

- The patient must have a separate room. If there is no separate room, this patient should be arranged in the same room with patients of the same pathogen.

- Wear clean gloves when entering the isolation room. During the process of patient care, gloves should be replaced after contact with things having high concentration of virus or bacteria (stools, drainage fluids, excretions, etc.).

- Wearing clean gown and shoe-covers when entering the patient room and putting them off before leaving the anteroom. After putting off the gown and shoe-covers, make sure that your clothes do not touch any surface of the environment or other things.

- Putting off gloves and gown before getting out of the room and performing hand hygiene immediately with disinfectant solution. After putting off gloves and having hand hygiene, hands must not touch any surface of environment or things in the anteroom.

- Patient transportation must be minimized. On-bed techniques (X-ray, ultrasonography, etc.) are recommended. In case transportation is required, a notice must be sent to the arrival. Before transportation, have the patient wearing mask during the transportation. In case of skin lesion, it must be covered to avoid spread of infectious source. Use designated special pathway to minimize exposure to other healthcare workers other patients and other people.

- Utensils and equipment of patient care: should be used one time for each individual patient. If it is impossible, they must be cleaned, disinfected and sterilized before using them to another patient.

5.2.2. Droplet Precautions

Droplet precautions require the following contents:

- The patient must have a separate room. If there is no separate room, this patient should be arranged in the same room with patients of the same pathogen. Arrangement with other patients may be allowed but the minimum appropriate distance must be over 2 meters.

- Wearing medical masks, goggles or face shield, especially when having close manipulation with the patient.

- Patient transportation must be minimized. In case of transportation, the patient must wear medical mask, use the special pathway to void infection to other healthcare workers, patients and people.

5.2.3. Airborne Precautions

When implementing aerosol-producing procedures over a COVID-19 patient, it is necessary to apply measures to prevent airborne transmission.

Air treatment and ventilation in the patient room are necessary to prevent the spread of the epidemic.

The measures to prevent airborne transmission include:

- Arrange the patient in a separate room. In case there is no separate room, it is recommended to arrange the patients in the same confirmed infection group or the suspected group in the same room.

- Ensure safe ventilation: run the system of natural ventilation, mechanical ventilation or combine both provided that the minimum circulating air volume must reach ≥12 air flow/hour. A system may be used to draw air outwards (underground, 10-15 cm under the floor) to the no-people area and avoid the re-circulation of contaminated air.

- Any person entering the isolation room must wear a Respirator mask (for example: N95 mask).

- Patient transportation must be restricted. Transportation can only be done in extremely necessary situations and the patient must wear medical mask when getting out of the room.

- Procedures must be performed in a single room with its doors tightly closed, with safe ventilation and far apart from other patients.

- In case of sputum sucking prescription, tools and non-open sputum sucking method must be applied to a patient in mechanical ventilation.

5.3. Strict compliance with respiratory hygiene rule

The recommended principles of respiratory hygiene are as follows:

- All patients or healthcare workers having any respiratory symptom must apply the principles of respiratory hygiene, including:

  •  Cover the mouth and nose with tissue when coughing and sneezing, and then discard it into the waste bin.
  •  In case no tissue is available, a person may cough onto the upper side of the elbow, NOT use the hand to cover mouth when coughing.
  •  Ask the patient who has symptoms of coughing or sneezing to wear medical mask when having close contact (<2m) or the healthcare worker examining a patient who has risk of COVID-19 via droplet transmission.
  •  Wash hands after having contact with excretions.
  •  Stand or sit at least 2 meters apart from a COVID-19 confirmed or suspected patient.

- Poster should be hung to instruct respiratory hygiene at those places easily to see: examination area, isolation ward.

5.4. Environment Control

5.4.1. Environment of surfaces of floors, walls, corridors

Environment control is the important measure to prevent COVID-19 infection. The following principles should be paid attention to:

- The surfaces in the environment must be leaned and disinfected with proper permitted disinfectant chemicals.

- Patches of blood or biological release or excretion as vomit, stool on surfaces of environment must immediately be eliminated with towel soaked in chemical having 0.5% active Chlorine (5,000 ppm), then wipe it with clean towel and clean it the second time with 0.05% active Chlorine.

Refer details in the section of Cleaning and Disinfecting surfaces in environment.

4.5.2. Ventilation

Proper ventilation must be assured at the following areas:

  • Patient reception areas, corridors, waiting room should not be tight and should be clear.
  • Patient room areas:
  •  The optimal isolation room is the negative pressure room.
  •  In case the negative pressure room is not available, the facility should use mixed air or natural ventilation, assuring ventilation in the isolation room must reach at least ³ 12 circulating airflow/hour.
  •  The room where aerosol-causing procedures are performed must have proper room ventilation (≥12 circulating airflow/hour).
  •  In case such a standard room is not available:
  •  Perform procedures in a room far apart from other patients. The procedure room must be well-ventilated, leeward, having 2-way convectional windows open towards a no-people area.
  •  A system to draw air outwards may be used. The drawn air must be released to an empty area, having no people, and must not release to the corridor or the surrounding rooms.

4.5.3. Vehicles, machines, beds and cabinets

Clean and disinfect them every day, at least twice and when necessary (between two patients, when a patient died, transferred or discharged) with appropriate permitted disinfectant chemical.

Refer details in the section of Cleaning and Disinfecting surfaces in environment.

4.6. Community transmission prevention

During the time to care a COVID-19 confirmed or suspected patient or a patient during the monitoring time, a healthcare worker must restrict contact with relatives or community until the risk ends, avoiding disseminating and spread across the hospital and the community.

The medical facility should assign a special group of healthcare workers to care the COVID-19 confirmed or suspected patients. During this process, the group of healthcare workers must not take care of other patients.

Propagate people restrict to go to epidemic zones. Those having arrived or those having close contact with a COVID-19 confirmed or infected patient should have self-isolation and monitor body temperature within 14 days. Come to the hospital right after a fever or symptoms of respiratory disease appear.

Those not having respiratory symptoms should:

- Avoid gathering and avoid coming to crowded places frequently.

- Keep a distance at least 2 meters off any person having respiratory symptoms (for example: coughing, sneezing).

- Do hand hygiene regularly: with alcohol-based solution for unsoiled hands or with soap and water for soiled hands.

- When coughing or sneezing, shield the mouth and nose with your elbow or with tissue, which must be immediately discarded right after use and do hand hygiene.

- Hands are recommended to avoid touching to eyes, nose, and mouth.

Those having respiratory symptoms are recommended:

- To wear medical mask and to have a visit as soon as possible in case of fever, cough, dyspnea, etc.

- To use and manage masks properly.

Mask management:

If someone wears a medical mask, it is necessary for him/her to use and discard it properly, ensuring the efficiency and avoiding risks of transmission related to the improper use and discard of mask.

Wearing mask must be duly as prescribed and technically. Do not overuse masks. Improper use of mask may spread pathogens.

Detailed guidance about putting on and putting off masks are provided in section of use of personal protective equipment.

5.6. Other principles of prevention and control

Many measures of infection control must be combined, including the process of triage, isolation, environment hygiene, waste management, proper use of process of putting on and putting off personal protective equipment; control of infection in transportation, operation and treatment of corpse, control of infection in laboratories.

 

 

TRIAGE, RECEPTION AND ISOLATION OVER COVID-19 CONFIRMED OR SUSPECTED PATIENTS

 

COVID-19 has high risk of spread so the tasks of triage, early detection and well-timed isolation are very important. A COVID-19 confirmed or suspected patient must be isolated immediately and measures to prevent transmission must be strictly applied.

1. Objective

Have triage over patients who come to visit in order to detect and isolate early a COVID-19 confirmed or suspected patient, whereby prevent the risk of COVID-19 infection from patients to healthcare workers, to other patients and across the hospital environment.

2. Principles for execution

  • The medical facility should establish the system to detect and respond quickly when there is a COVID-19 confirmed or suspected patient.
  • The medical facility should make scheme for triage, categorization, and management of COVID-19 confirmed or suspected patient right when they come and have examination.
  •  The medical facility must execute measures to prevent and control infection strictly (standard precautions and transmission-based precautions).
  •  Do the task of categorization upon patients as soon as they come to have examination of the medical facility with the triage questionnaire.
  •  Arrange special area/examination room for those patients having or not having acute respiratory symptoms (cough, fever, etc.) but having the epidemiologic factors (arrive at or pass Hubei Province, China within 14 days) (refer Guidance at gathered isolation unit for prevention and control of COVID-19, enacted with Decision 344/QD-BYT dated February 07, 2020 by the Ministry of Health).
  •  When a COVID-19 confirmed or suspected patient is detected, that patient must be isolated in a timely manner (according to the signs of disease and the informing epidemiologic factors).
  •  Declare, inform, report disease cases as regulated.

3. Scope of application: All medical facilities.

4. The task to prevent and control COVID-19 infection.

Medical facilities should strictly execute the processes and regulations on prevention and control of epidemic spread enacted by Ministry of Health.

All resources must be mobilized to control COVID-19 infection; cure confirmed patients, prevent infection to other patients and limit death; actively combine with other forces to zone pestholes, transport, run emergency, isolate, treat patients, treat the environment of pesthole in the timely manner.

Medical facilities should actively prepare and execute the following activities:

4.1. Organization, personnel

- Establish the COVID-19 prevention & control Steering Committee at hospitals, consisting of: The Directors, Department of General Planning, Outpatient Department, Accident & Emergency, Infectious Disease, Pediatrics Department, Respiratory Department, Administrative Personnel Department, Infection Control Department, Facility Department, Pharmacy, Nursing Department, Administrative Personnel Department and Agency Health Unit. At central-level and province/centrally-run city, the Steering Committee may have subcommittees of treatment and subcommittees to prevent and control infection, subcommittees of logistic, etc.

- Based on the actual conditions of each hospital, the Hospital Management shall determine which department in charge of reception and treatment of COVID-19 confirmed or suspected patient. The Department in charge of reception, triage, and treatment of patients must have enough conditions for proper isolation. Staff of this department must be fully trained in infection control, especially the use of personal protective equipment as instructed to prevent infection in the hospital.

4.2. Reception and isolation

- Zoning the risk and streaming the movement of COVID-19 confirmed or suspected people in the hospital are as follows:

  • The high risk zone (red) comprises of the departments receiving and treating COVID-19 confirmed or suspected patients (for example: isolation ward; Outpatient department; Emergency & Resuscitation Department, Infectious Disease Department, Laboratory, etc.).
  •  The medium risk zone (yellow) comprises of departments receiving patients having cough or fever (Example: examination room for patients having cough and fever of Outpatient Department, Emergency Department, Respiratory Department, Pediatrics Department);
  •  The low risk zone (green) comprises of the departments less likely receiving, examining and treating COVID-19 confirmed or suspected patients (for example: Surgical Department, Maternity Department, etc.).

- The risk zoning helps the hospital have the foundation in assignment, development of scheme of reception, treatment and concentration of its limited resources to the task of prevention (vehicles, personnel, training, monitoring) for high risk zones.

- The hospital must have plan to zone isolation wards, arrange personnel, vehicles, etc. for the situation of scattered and mass COVID-19 confirmed or suspected patients.

4.3. Conditions and means

4.3.1. Hand hygiene means

Soap, alcohol-based hand hygiene solution, tissue or disposable hand tissue must be available at all necessary places.

4.3.2. Personal protection

 Anti-epidemic gown, apron, paper hat, medical mask, N95 mask, goggles (or face shield), boots, shoe-cover, medical gloves and hygiene gloves.

4.3.3. Equipment

- Ventilation assisted equipment and other means of emergency and resuscitation (handheld oxygen saturation meter, monitoring machine, bed X-ray machine), oxygen and the system to create and supply oxygen, the system of close sputum sucking;

- HEPA air disinfection filter.

For high effectiveness of COVID-19 transmission control, the above-mentioned means must always be available at each receiving and treating area even in or not in epidemic time. Healthcare worker must be trained to master the use of personal protective equipment and other hospital regulations in infection control.

4.3.4. Disinfectant chemicals – surface and tool disinfection

The facility must make estimate, purchase and provision of sufficient chemicals for tool treatment; environment surface disinfection and cleaning; hand hygiene; waste treatment in case of epidemic.

4.3.5. Isolation room

The hospitals must arrange standard isolation wards or isolation rooms as regulated and must always be available for epidemic situation.

Other medical facilities must prepare wards (rooms) to receive and triage COVID-19 confirmed or suspected patients.

4.3.6. Medications

Medication list is subject to the treatment protocol.

4.4. Training

Medical facilities must establish the scheme and hold training courses to educate all healthcare workers at the facility on COVID-19 infection control. The Infection Control Department will be responsible for the contents, programs, materials, means to educate the theory and practice for healthcare workers as in materials of Ministry of Health.

4.5. Drill

The COVID-19 prevention and control Steering Committee at medical facilities has to hold drill to examine, assess, and learn from experience upon the defective contents for modification, correction and improvement of the facility’s plan of epidemic prevention and control in line with those of the locality, region, and country.

Some notable points in the contents of drill are as follows:

  • Early control: Stream, screen, diagnose, early isolate patients having symptoms of COVID-19 infection or suspected patients who come for examination and hospitalization. Duly execute regulations in patient transportation in the hospital, department transfer, hospital transfer ensuring safety of healthcare workers, transporters and the community.
  • Ensure necessary conditions for the reception, treatment and organize prevention and isolation in the medical facility.
  • Ensure that healthcare workers use personal protective equipment properly, prepare adequate number of available means and have solutions when the supply of personal protective equipment is limited.
  • Comply with standard precautions and transmission-based precautions (via droplet, contact and perhaps airborne transmission) by heath are workers. Ensure compliance with regulations, hand hygiene process, disinfection and sterilization of medical equipment, cleaning and disinfection of the isolation ward and leaning the hospital environment.
  • Practice infection prevention over healthcare workers, patient families, visitors in medical waste management, linen management, eating and drinking things of patients in the isolation ward, provide guidance on prevention of infection when the patient died
  • Pay proper attention to other hospital-acquired infection related to the care of COVID-19 confirmed or suspected patients (lung infection, septicemia, urinary infection, etc.).

4.6. Inspection and monitoring

  • The Infection Control Department has the professional specialty in inspection and monitoring upon the COVID-19 infection control; set the process of infection control applied in the hospital after it is approved by the Infection Control Committee and the Anti-Epidemic Steering Committee of the hospital, submitted for approval by the Hospital Management who then monitor the compliance with the process of epidemic prevention and control and infection control.
  • The General Planning Department combines with the Infection Control Department monitor, make statistics, give timely notice about the number of COVID-19 confirmed or suspected patients and the healthcare workers having close contact, inspecting and monitoring the execution of regulations on infection control.
  • The Nursing Department combines with the Infection Control Department, the General Planning Department and the head nurses of clinical departments, head technicians of subclinical departments to inspect and monitor the execution of regulations on infection control.

4.7. Assignment and execution

The Directors, leaders of departments and relevant persons are responsible for the contents of activities on COVID-19 infection prevention at medical facilities.

The contents on infection control must be shown in the scheme of COVID-19 prevention and control scheme of the hospital.

The Director has the duty to fully equip infrastructure, purchase equipment, materials, chemicals, necessary vehicles to serve the task of infection prevention. The isolation ward must be arranged at appropriate place. The facility must have the scheme to renovate, upgrade and build the isolation ward duly as guided.

4.8. Expenditure

Expenditure is applied under regulations on epidemic prevention and control of the Government. Purchase and spending must be under regulations. During the epidemic time, when the Ministry of Health or an authority declares epidemic state, the spending will be applied urgent epidemic prevention and control regulations.

The Hospital Director is responsible for the allocation of budget and expert for regular activities in infection control. The Hospital is required to have a backup budget for epidemic prevention and control.

5. Triage, isolation of COVID-19 confirmed or suspected patients

5.1. Preparation of infrastructure and means

  • Arrange, establish the isolation ward and isolation room to meet the isolation requirement.
  • Personal protective equipment (Refer the Guidance on use of personal protective equipment).
  • Hand hygiene utensils must be available from patient reception areas to the triage, examination and treatment area.
  • Essential tools, equipment and disinfectant chemicals used in patient care and treatment.
  • Means to collect waste, tools, linens, etc.

5.2. Steps of execution

Each medical facility must have triage area right at the examination rooms (as at the security post, patient reception desk). There must have at least one examination room to isolate the cases of cough and fever with unknown cause. The staff in charge of triage must instruct the patient the measures of prevention and isolation as soon as the patient comes into the examination room.

* The diagnoses to early detect a COVID-19 infected or suspected patient are as follows:

- There is an epidemic factor within 14 days before the symptom onset:

  •  A patient returning to Vietnam from a COVID-19-hit region or having contact with someone returning from such region.
  •  Having contact with blood or body fluid of a patient who has been confirmed or suspected COVID-19 infection in the epidemic-hit region.
  •  Having resided or arrived at a COVID-19-hit region within 14 days;
  •  Having directly contacted animal from the epidemic area.

- Having clinical signs of the disease:

  •  Having high fever suddenly ≥ 380C; headache or muscle ache may appear.
  •  Cough and dyspnea.
  •  Having signs of acute pneumonia or acute respiratory failure (Refer the Guidance on diagnosis over those suspected of COVID-19 infection of the Ministry of Health, page 8).

- When having the symptoms or history as mentioned above, the patient should be arranged in the isolation ward, isolated from other patients as soon as possible as the steps in Instructive Chart (Appendix 1).

- During the epidemic time, instructive boards should be hung at the entrance (Security gate) and the examination room to instruct patients, families of patients having symptoms of fever, cough to come directly to the examination and triage area, not let them go to other areas.

- The areas of waiting, examination, procedures for the COVID-19 infected or suspected patients must be assured well-ventilated, with at least more than 12 airflow circulating each hour. This can be achieved by opening all windows and doors in the same direction in case of natural ventilation. If the hospital runs the system of central air-conditioning, the ACH index must be added and the safety of the system of central air-conditioning must be checked regularly and periodically. 

- A family member accompanying a COVID-19 infected or suspected patient should be considered to have exposed to COVID-19 and must also be screened to the end of monitoring time as regulated to help early diagnosis and to prevent the epidemic-causing ability of COVID-19.

- In case transportation is required, the transporter must use personal protective equipment and dedicated vehicle. Contaminated things, the transporting vehicle, discarded things and wastes of the patient must be collected and treated as regulated.

* Notes:

- Those staff who directly care for patients must strictly execute preventive measures such as: wearing personal protective equipment; wash hands with soap or other disinfectant solutions after each contact with patients (refer the section of hand hygiene and use of personal protective equipment).

- Patients must wear medical masks.

- Minimize the contact with or transportation of patients.

- Execute personal hygiene, use hygiene solutions, disinfect the nasopharyngeal tract.

- Disinfect the patient-transporting vehicles after each use.

- Make list of persons having close contacts and monitoring their health within 14 days since the last contact. Advise the contact person on the signs of disease and measures of prevention and control so that they can apply self-prevention and self-monitoring, early detecting symptoms of COVID-19 confirmed or suspected patients. If there is any symptom, it must immediately be reported to the nearest medical facility for timely diagnosis and treatment.

5.3. Inspection and supervision

- The Department of Infection Control, Department of General Planning, and the Nursing Department have the duty to inspect, supervise and train the implementation of isolation of healthcare workers.

- Contents of supervision:

  •  The patient room/ward must meet the standard of isolation.
  •  Be equipped with all personal protective equipment as regulated (clothing, hat, mask, goggles, gloves, boots,).
  •  The compliance awareness by healthcare workers in isolation in each stage of diagnosis and treatment.

- Supervision is done by direct observation and the results are recorded into the Supervision note.

Time for isolation of COVID-19 confirmed or suspected patients: Isolate and treat patients at medial facilities under the Guidance by Department of Health.

Announcement of a disease case:

- Announcement must be cascaded across the medical facility duly as regulated and degraded: The Clinic/Department of Emergency having a COVID-19 confirmed or suspected case must immediately give notice to the following persons:

  •  The patient himself/herself and his/her families.
  •  The members of that shift (if in duty hours) or all members of the department (in office hours).
  •  The hospital management and the relevant departments (Department of General Planning, Department of Infection Control, Nursing Department, etc.).

- Announcement outwards the medical facility: Urgent written notice must be reported on all confirmed or suspected cases to the superior health management and to the leaders of equivalent preventive health authorities as regulated.

Factors ensuring the triage, early detection, timely isolation, treatment and management of COVID-19 infected patients who are able to spread epidemic in medical facilities:

- Establish an epidemic prevention & control Steering Committee.

- Establish the specific and detailed process to receive and treat patients in screening, detection and isolation of COVID-19 confirmed or suspected patients right at the areas of examination room to the isolation ward.

- All healthcare workers must be trained on clinical symptoms, treatment, spreading ways and process of preventive isolation in the hospital.

- Have enough means ensuring strict isolation.

- Inspect and assess the availability whether the epidemic has come/not come yet.

 

 

GUIDANCES ON ESTABLISHMENT OF ISOLATION WARD IN A MEDICAL FACILITY

 

COVID-19 is a very highly infectious disease. The early isolation upon a COVID-19 confirmed or suspected patient plays a very critical role. To execute well the isolation measures, the medical facilities must always have isolation ward and isolation room with full equipment. Healthcare workers must be trained in compliance with technical procedures in isolation:

- The medical facilities must establish the isolation area right at the patient-reception place, including the waiting area for COVID-19 suspected patients, triage area, isolation room and personal protective equipment, utensils for the treatment and care for patients to receive COVID-19 patients.

- The Outpatient Department, Emergency Department, Pediatrics Department, Infectious Disease Department must prepare an isolation room with full of necessary equipment to opportunely isolate patients if necessary.

1. Isolation ward pattern

1.1. Objective

- Restrict and control the spread of COVID-19 in the environment of examination and treatment facility and the community, especially for healthcare workers, patients, families and visitors.

- Isolate the pathogen in the isolation ward for treatment.

1.2. Principles for isolation ward establishment

- The isolation must be located at the end of the corridor, deserted place, at the end of the main wind direction.

- Patient families must not join the care and visitors must be minimized.

- The isolation ward should be divided into 3 different areas subject to the infection risk:

  • Low-risk infection area: The Administration area, the workplace of healthcare workers. This area must have the green signboard and restricted. Healthcare workers should wear medical masks.
  • Medium-risk infection area: The area of corridor, the anteroom where utensils of care and treatment are stored. This area must have the yellow signboard. Only healthcare workers are allowed to come to this area with full and appropriate personal protective equipment.
  • High-risk infection area: The reception room, emergency room, treatment room, restroom, utensil treating room. This area must have the red signboard. Healthcare workers must have full personal protective equipment and must do hand hygiene after each contact with a patient, with surfaces in environment and before the isolation ward.

1.3. Requirements at an isolation ward

1.3.1. Isolation ward design in province-level, (centrally-run) city-level hospitals

- Functional chambers:

1) Administration chamber.

2) Patient-reception chamber.

3) Patient-treatment chamber.

4) Chamber for severe COVID-19 patients of emergency (having full emergency means and treatment used individually for each patient).

5) Patient-retaining chamber for COVID-19 suspected patient.

6) Tool-treatment chamber having all equipment for initial disinfection: tool washing basin, drying cabinet and disinfectant chemicals.

7) Chamber used to store essential things for patient care and treatment.

8) The patient restroom must have hand wash basin, disposable hand tissue and soap for hand wash.

9) Bathroom for healthcare workers having hand wash soap.

The chambers in the isolation ward must have hand wash basin, hand tissue, alcohol-based hand hygiene solution, hand wash soap. The pathway must be from the low-risk to the high-risk infection area.

10) Ventilation system: The optimal measure is that the negative pressure system is equipped at the isolation room. In case this system is not available, it is required to have the forced airflow running from the low-risk area to the high-risk area (from the green to the red area). The frequency of airflow must reach at least 12 times/hour. Air released from the isolation ward must be disinfected with UVC or with combined method of disinfection and HEPA filtering.  In case such a system is not available, the released air must be blown into an empty environment having no people.

11) The floors and walls (with the minimum height of 2 meters) should be pressed with eramic tiles for easy cleaning and disinfection.

12) The corner of the house and the floor should be designed with obtuse or rounded angle, avoiding acute angle for easy cleaning and not to gather soil.

13) The windows must be made from materials that are easily to be cleaned (glass, few items, easily to be washed and cleaned).

1.3.2. Isolation room design in district-level hospitals

1) Those hospitals in the region of epidemic risk should always put aside an area in the Infectious Disease Department or a special area inside the hospital to receive COVID-19 confirmed or suspected patients.

2) The isolation room should also be arranged so that it is not near the places of other patients or crowded place.

3) The isolation ward may not have all functional chambers as that of the upper-level hospital but it must at least have the following rooms:

  • Room to examine and receive patients.
  • Room to isolate and treat severe patients.
  • The restroom and utensil-treating room (it may be located right in the isolation room).

4. The isolation ward should have the system of mechanical ventilation flowing from the isolation to a deserted place with windows to circulate air with the outside environment.

 


 

A: Disinfection place

B: Cabinet for PPE, clean linen and tools

C: Bag for after-use PPE, waste, soiled linen

D: Hand-wash basin with soap, alcohol-based hand hygiene solution

E: Windows opening to the outside, far from residential area, without people

Figure 2. Diagram of COVID-19 confirmed isolation room

1.4. Patient bed arrangement in the isolation room

It is most preferable to arrange each COVID-19 confirmed patient in a separate isolation room (if possible).

In case of not possible or if there are too many OVID-19 confirmed or suspected patients hospitalizing, the suspected patients may be arranged in the same room (group isolation), COVID-19 confirmed patients may be arranged in the same room. Patients suspected of infection and waiting for test result may be arranged in the same room. The distance between two beds must be at least 2 meters to prevent droplet transmission.

2. List of essential things necessary at the isolation ward/room:

- These things must always be available in the isolation ward, isolation room, located on board or in the anteroom’s cabinet right in front of the isolation room.

- Those departments and units (such as environmental hygiene, waste treatment, patient transportation, etc.) related to the task of care and treatment of COVID-19 confirmed or suspected patients must wear all appropriate personal protective equipment (rubber boots, aprons, masks, goggles, etc.).

- List of tools and personal protective equipment that must always be available in the isolation ward and must be checked and sufficed on daily manner. It is notable to have all sizes for users and the mandatory minimum number must always be available (see Table 1).

Table 1. Means and tools must always be available
in the isolation ward/room

(The daily minimum number in case there are patients hospitalized for monitoring and treatment)

No.

Tools

Number

 

Personal Protective Equipment (PPE)

 

1

Clean gloves of all sizes

150

2

Protective outfit

30

3

Goggles, face shield

30

4

Head hat

50

5

Boots or shoe-cover

30

6

N95 mask

20

7

Medical mask

50

 

Other essential things

 

1

Patient clothes

05

2

Bed sheet

05

3

Disposable hand tissue

30

4

Tissue bin

01

5

Hand wash soap and alcohol-based hand hygiene solutions

05

6

Soap holder and alcohol-based hand hygiene solutions

 

7

Cleaning gloves

10

8

Towel to wipe surfaces and paper to absorb scattered fluids

05

9

Bag/bin containing kinds of waste with symbol of infectious waste

10/01

10

Bag for soiled linen

05

11

Bin with lid for soiled linen

01

12

Bin for soiled tools

01

13

Chemicals for initial disinfection and cleaning

 

 

 

3. Ventilation

Ventilation enhancement is the important measure in COVID-19 prevention and control. There are 3 ways to enhance ventilation:

3.1. Mechanical ventilation:

A negative pressure room is created by bringing clean air into the room and drawing contaminated air outwards so that it must have at least 12 airflow exchange every hour (ACH) and the negative pressure must be at least -3Pa. Air released will be led through the preliminary filtration system and HEPA filtering combined with disinfecting with UVC.

3.2. Natural ventilation:

Airflow brought into and released outwards the isolation room or ward through the main entrance or windows. The patient room has 2 windows located opposite. If all 02 windows are opening, they ensure ventilation in the patient room for at least 12 ACH. A patient room having natural ventilation should be located leeward, having 2-way convection windows opening towards a deserted place.

3.3. Mixed ventilation:

The natural ventilation is combined with the system of fan to blow air outwards. Air must not be released to crowded places, the corridor or into other rooms. Air released from exhaust fan must be disinfected with UVC or a combined way between disinfection and HEPA filtering. In case such a system is not available, the exhaust fan must be located to release air to a deserted environment.

The capacity, number of exhaust fans must be counted subject to the room volume to ensure the ventilation at least 12 ACH.

 

 

USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)

 

Personal protective equipment are an essential means to protect healthcare workers from the risk of infection when they have a close contact with blood, secretions and respiratory droplets carrying infectious pathogens of patients. PPE is also used to protect patients from being infected with resident and transient microorganisms from healthcare workers and the hospital environment. Use of PPE when taking care of infected or suspected COVID-19 patients is the most important measure in preventing infection for healthcare workers.

1. Objectives

To prevent the risk of COVID-19 infection from patients to healthcare workers, other patients and visitors, and the spread to the environment surrounding patients and the community

2. Scopes of application

All healthcare workers, patients’ relatives, visitors, people having contact with confirmed or suspected COVID-19 patients or specimens from confirmed or suspected COVID-19 patients.

3. Principles of implementation

3.1. General principles

- Use PPE as recommended by standard precautions combined with transmission-based precautions suitable to the situation in care and treatment of confirmed or suspected COVID-19 patients.

- Ensure the availability of PPE dotation in isolation areas, anteroom of isolation rooms, laboratory, waste treatment areas and corpse management areas.

- PPE is only effective when used in conjunction with other infection control measures such as organizing the process of screening, isolation, surface and environmental sanitation and waste management.

- It is necessary to comply with the instructions and procedures of putting on and taking off PPE.

3.2. Rules for using personal protective equipment

  1. Always wear PPE when contacting, examining, and taking care of confirmed or suspected COVID-19 patients.

  2. The practice of putting on and taking off PPE must be done competently before taking care of infected or suspected COVID-19 patients and must be supervised by a trained member.

  3. Prepare adequate PPE suitable to the situation to be implemented.

  4. Putting on and taking off PPE must be done in the anteroom before entering and after leaving the isolation room. Avoid touching or adjusting PPE in the isolation room.

  5. Ensure PPEs cover the entire body.

  6. Change gloves when moving from one patient to another patient, change gloves if torn, perform hand hygiene before putting new gloves on.

  7. When taking off PPE, pay attention to the following principles:

  • The outer surface of PPEs has a high risk of contamination, thus turn the outside in and do not shake while taking off PPE.
  • The front of PPE has a higher risk of infection than the back. Avoid touching the front of PPE.

  8. PPE is disposable, and is infectious wastes; it must be discarded into infectious waste containers (yellow containers) immediately after removing. Waste containers must be large enough and must have automatic lids.

4. Types of personal protective equipment

4.1. Type of personal protective equipment

  In fact, there are many types of PPE, which can be classified into two categories as follows:

  Type 1: Detached pants, gowns and caps

Waterproof gowns or gowns with waterproof covers.

Waterproof pants.

Waterproof aprons

Medical masks

-   High filtration capacity masks (e.g. N95 respirators)

Goggles or face shields.

Medical gloves.

Hood caps (cover the entire head and neck).

High-length shoes covers

Rubber boots

Type 2: Coveralls and cap:

Coveralls and caps.

High-length shoes covers.

Waterproof aprons.

Medical masks.

N95 respirators.

Goggles or face shields.

Medical gloves.

Rubber gloves.

High-length waterproof shoes covers.

Rubber boots.

4.2. Technical criteria

Goggles and face shields must fit tightly against the face to prevent fluid from absorbing.

Medical masks must be qualified, waterproof and have metal strip that may bend to fit the nose bridge and prevent the air and droplets from passing through.

Masks have a high filtration capacity (e.g. masks meet N95 or FFP2 standards or equivalent).

Gloves: It is recommended to use gloves made of nitrile rather than latex with appropriate sizes for user’s hands

Gowns has a mid-thigh length, long sleeve, plastic wrist and aprons must be impermeable to blood and fluids.

Rubber boots should not be torn or punctured with appropriate sizes for user’s feet.

Shoes covers should be knee-length, waterproof material, and slip resistance.

Caps must cover head and neck, with a front opening to remove later.

Clothes worn beneath personal protective equipment.

 

a. Goggles with headband

b. Goggles with ear-hanging frame

Figure 3:Goggles

Figure 4:Face shield

 

 

 

Figure 5:Types of mask

 

 

Figure 6: Gowns and aprons

Figure 7: Hood cap

Figure 8: Clothes worn beneath gowns

    
 

5. Procedure of putting on and taking off personal protective equipment

5.1. Putting on and taking off mask

5.1.1. Medical mask:

* Technique to put on masks:

- Hand hygiene.

- Open the package; remove the mask from the bag, one hand holds one side of the mask.

- Place the mask on the face, the waterproof side (blue) faces outwards, the absorbent side (white) turns inwards. One hand secures the front of mask on the face, another hand places one strap around the ear then repeat for another side.

- Use the tip of index finger to mould the metal strip to fit snugly over the nose bridge and face.

- Use 2 fingers to hold the lower edge of mask and pull down slightly, extend the mask to fully cover the bottom of the chin

* Technique to take off mask:

- Remove the mask strap, do not let hand touch the mask, discard the mask into the waste container as prescribed.

- Hand hygiene.

5.1.2. High filtration capacity mask (N95 Respirator)

* Technique to put on respirator:

- Hand hygiene

- Open the package, place the mask on the palm of hand, the metal edge covers nose bridge and faces forward, let the strap drop freely under the hand.

- Place the mask under the chin, the nose cover faces upwards.

- Pull the top strap over the head and set it at the top back of head over the ears. Pull the bottom strap over the head and place it at the back of the neck below the ears. Do not let two traps overlap each other behind the head.

- Check and adjust the strap if twisted or twirled.

- Place tips of 2 index fingers at the top of nose bridge, mold the nose cover to help the mask fit snugly over the nose.

- Tightness test of the mask:

+ Inhalation test (negative): exhale slowly, if the respirator is tight, the negative pressure helps the respirator cover the face snugly. If the respirator is not tight, the air will pass through the opening into the mask, thus it is necessary to adjust the tension of the strap and repeat the inhalation test again.

+ Exhalation test (positive): exhale strongly, if the mask is tight, positive pressure creates airflow inside the mask. If the mask is not tight, it is required to adjust the tension of the strap and repeat the exhalation test again.

* Technique to take off respirator:

- Remove the bottom strap by lifting the strap over the head, then pull the top strap over the head, do not let your hand touch the mask when removing.

- Hand hygiene.

5.1.3. Points to note when putting on and taking of masks

- Wear masks with the right upper and lower direction.

- Wear masks with the right inside and outside surface.

- Do not touch the inside surface of mask while wearing.

- Place masks carefully to cover mouth and nose.

- Adjust the nose strip and the strap to ensure the mask fit the nose bridge and face snugly.

- Do not touch the front of mask when removing.

- After removing or whenever accidentally touching used masks, it is required to wash hands with alcohol-based hand sanitizers or wash hands with soap and water.

- Change masks after performing a clean/aseptic procedure, as soon as a mask is contaminated or damp/wet or after every shift.

- Do not reuse used masks.

5.2. Order to put on personal protective equipment

Step 1:  Hand hygiene.

Step 2: Wear boots/shoes cover.

Step 3: Put on pants and gown (wear apron if indicated).

Step 4: Wear mask

Step 5: Wear goggles (for goggles with ear-hanging frame)

Step 6: Wear hood cap to cover hair, head, ears, and mask straps completely.

Step 7: Wear face shield or goggles (for goggles with headband outside the hood cap)

Step 8: Wear clean gloves

5.3. Order to take off personal protective equipment

5.3.1. Type of detached pants, gown and cap

Step 1: Remove gloves. Roll the inside out when removing, then put them into waste container. In case of wearing apron, remove the apron, release the lower strap first, then release the upper strap, roll the inner surface of the apron out, and put in the waste container.

Step 2: Hand hygiene

Step 3: Remove gown, roll the inside out and put it into waste container.

Step 4: Hand hygiene

Step 5: Remove pants and boots/shoes cover simultaneously, turn the inside out and put them into waste container. In case of wearing boots, place the boots in a container with disinfectant solution.

Step 6: Hand hygiene

Step 7: Remove face shield or goggles

Step 8: Hand hygiene

Step 9: Remove cap by slipping hand into the cap

Step 10: Remove mask (by holding the strap behind the head or ears)

Step 11: Hand hygiene

5.3.2. Type of coveralls and cap

Step 1: Remove gloves. Roll the inside out when removing, then put them into waste container. In case of wearing apron, remove it by releasing the lower strap first, then releasing the upper strap, roll the inside of the apron out, and put into the waste container.

Step 2: Hand hygiene

Step 3: Remove face shield or goggles

Step 4: Hand hygiene

Step 5: Remove cap, coveralls. When removing, turn the inside out and put them in the waste container.

Step 6: Hand hygiene

Step 7: Remove boots or shoes cover, turn the inside out and put them into waste container. In case of wearing boots, place the boots in a container with disinfectant solution.

Step 8: Hand hygiene

Step 9: Remove mask (by holding the strap behind the head or ears)

Step 10: Hand hygiene

Note: Remove PPE at the anteroom of isolation rooms and areas.

6. Inspection and monitoring of use of personal protective equipment

Infection Control Department and Nursing Department are responsible for inspecting, monitoring and training the use of personal protective equipment for healthcare workers:

Content of monitoring:

PPE are available all the time at the anteroom of isolation rooms and areas

Healthcare workers use the necessary PPE adequately and properly.

Used PPE should be sorted, collected and treated.

Method of monitoring: by direct observation and by recording in monitoring form.

 

                                        

HAND HYGIENE

 

Hand hygiene is one of the important measures to help prevent and control COVID-19 infection. The hand hygiene needs to be done regularly all the time, all places at the right time in accordance with 5 moments of hand hygiene during care and treatment of the patient.

All medical facilities must

1. Hand hygiene equipment

Fully supplement hand hygiene facilities at all areas with people infected or suspected of COVID-19.

1.1. Hand hygiene equipment with soap

- The hand hygiene sinks must be placed in the isolation rooms, buffer rooms, administrative rooms, drug and fluid preparation rooms, testing rooms, nutrition rooms, waste and dirty clothes treating area, mortuary convenient for patients and healthcare workers to use.

- The hand hygiene sinks must have soap solution, clean water, container of disposable hand towel (in paper or cloth)

Some specific provisions:

- The hand hygiene sinks must be sufficiently deep to avoid water splashing outside and splashing into the washers, with no corner, smooth surfaces, no stains and stagnant water. The height of the sink is in line with the height of the hand cleaners.

- Faucet: fixed to the wall. The handle should be automatic, pedal or lever.

- Water system: tap water, water pipes should be placed in the wall, but must be easy to install, clean and disinfect when necessary.

- Soap and soap holder for hand hygiene: it is best to use liquid soap, put in a closed container, with a standard quantitative pumping, fitted properly. If using bar soap, you need to keep in a box with a tight lid, keep it at dry place and avoid splashing water.

- Disposable hand towel: may be in disposable paper or reused cotton towel put in tight box and easy to take it out.

- Dirty towel container: is conveniently designed so that it is easy to put towels into the container without touching the lid.

Fig. 9 Washing hands under running water

 

1.2. Hand hygiene equipment containing AlcohoL/chlorhexidin

- Equip vials (bottles) of hand disinfectant solution containing 60% - 80% alcohol or chlorhexidin in all areas where patients are taken care of, at each bed head of severe patients or in emergency conditions. On injection or dressing change trolley, medical examination tables. On the wall right next to the entrance (door) to the patient room, buffer room, isolation room, in front of the elevator door, corridor, etc. where there is a risk of exposure to patient’s blood, body fluids.

- Regularly changing and sanitizing bottles of hand-disinfecting alcohol solution and making sure the bottles are available at designated locations.

- Bottle of hand-disinfecting alcohol solution with a standard pump, fixed to the wall or hung at the patient’s bed head, in front of the patient room, injection trolley, etc.

2. Hand hygiene indication

2.1. Hand hygiene with soap and clean water

- Whenever hand touches blood and body fluid which can be visible, during the care and treatment of the patient (performing invasive procedure, patient body hygiene care, handling of dirty equipment, waste, etc.) even though gloves are worn but suspected of gloves puncture or accidental removal leading to exposure to source of infection.

- Hand hygiene with soap and water should be done before and after working session, after going to the toilet, after collecting cloths, tools, waste, etc.

2.2. Hand hygiene with alcoholic solution

- Only do hand hygiene with alcoholic solution only when the hands are dry, no blood stain and body fluid is visible, during care, treatment, after removing the personal protective equipment.

- In places where hand washing sink cannot be installed and places where care operations are not at risk of visual contact with blood and body fluids possibly detected with naked eyes.

- Indication of hand hygiene with alcoholic solution: similarly as in hand hygiene with soap and water in case of visible blood or body fluid.

- Moments when healthcare workers need to do hand hygiene: 5 moments when healthcare workers must comply with hand hygiene (as recommended by the World Health Organization)

 

In addition, hand hygiene must be done in some of the following cases:

In the procedures for putting on and off the personal protective equipment

Before wearing gloves

When transporting patient from infectious place to clean place

Before finishing work at isolation area and going outside.

Before going home.

3. Techniques

3.1. Hand hygiene with soap and water (Figure 11)

- Step 1: Wet your palms with water. Take the soap and rub your palms together to create bubbles.

- Step 2: Rub one palm over the back of the hand and space of fingers of the other hand and vice versa.

- Step 3: Rub your palms together, strongly press the space of fingers.

- Step 4: Rub the outside of the fingers of one hand into the palm of the other.

- Step 5: Use this hand to turn the thumb of the other hand and vice versa.

- Step 6: Turn these finger tips into the palm of the other hand and vice versa. Wash your hands under running water.

Fig 11: Hand hygiene techniques with soap and clean water

3.2. Hand hygiene with alcoholic solution (Figure 12)

- Step 1: Use 3ml - 5ml of alcoholic/chlorhexidin hand sanitizer and rub 2 palms together.

- Step 2: Rub one palm over the back of the hand and space of fingers of the other hand and vice versa.

- Step 3: Rub your palms together, strongly press the space of fingers

- Step 4: Rub the outside of the fingers of one hand into the palm of the other hand.

- Step 5: Use this hand to turn the thumb of the other hand and vice versa.

- Step 6: Turn these finger tips into the palm of the other hand and vice versa until it is dry.