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 examination and treatment establishments 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 or hands.
Transmission by contact is the most common way of spreading microorganisms from a patient to another or a healthcare worker (healthcare worker) 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 examination and treatment establishment.
Droplet transmission: Droplet transmission occurs when the recipient's mucosa (nasal mucosa, conjunctiva, and less frequently the oral mucosa) encounters droplets of 5µm 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.
Airborne transmission: Airborne transmission is infection through airborne particles or through aerosols (<5 µm in size). Occurs when a healthy person breathes in airborne particles or aerosols containing virus or bacteria that are suspended in the air. The form of infection can occur in several diseases such as seasonal flu, H1N1 flu, H5N1 flu, COVID-19, etc. when performing diagnostic procedures,aerosol airway manipulations in infected people.
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 healthcare workers 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 healthcare workers. The most commonly used personal protection equipment 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 personal protection equipment.
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 (usually a room or a limited area) circulating per hour (air change per hour – ACH or ACPH).
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, standard for medical masks is regulated according to TCVN 8389-2010 standard.
Respirators mask: In this Guideline, 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).
PRINCIPLES AND MEASURES TO CONTROL SARS-COV-2 INFECTION
1. Generalities on SARS-CoV-2 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. 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 (Figure 1). 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. Structure of SARS-CoV-2
In late 2019, in Wuhan, China, there was an outbreak of pneumonia caused by a strain of a Coronavirus. Chinese scientists then subdivided a totally new Coronavirus strain (at first WHO marked it as 2019-nCoV, and officially named SARS-CoV-2 causing COVID-19 epidemic). This strain of virus is found to have the gene sequence resemble at least 70% with SARS-CoV-1.
The first case was confirmed in China on December 08, 2019. As of December 08, 2020, after one year of epidemic outbreaks in 237 countries and territories, there were 68 million cases of COVID-19 worldwide, of which 1,550,263 people died, the number of deaths and new infections daily is still growing, at more than 500,000 new cases and more than 8,000 deaths every day. In Vietnam, up to the date of December 08, 2020, 1,367 people have been confirmed to be infected with SARS-CoV-2, of which 35 were fatal.
SARS-CoV-2 is mainly transmitted by droplets in the close proximity to infected people with SARS-CoV-2 and by contact. Air transmission may occur in areas where aerosol generation procedures are performed, particularly within close proximity (<2 meters) and in enclosed, poorly ventilated areas.
Currently, there are no specific treatment drugs, and vaccines are being studied and used in a number of countries, so important measures to prevent SARS-CoV-2 infection are to wear masks, hygiene hands, and hygiene environment, keep distance, and avoid crowds.
2. Disease case definitions:
2.1. Possible case
Possible cases shall include the following cases:
A. Patients show symptoms of fever and/or acute respiratory infection that cannot be explained by other causes.
B. Patients show any respiratory symptoms AND has traveled to/been through/residence in/back from epidemiological areas* where ongoing community transmission of COVID-19 in the 14 days prior to onset of symptoms OR in close contact (**) with a confirmed COVID-19 case in the 14 days prior to onset of symptoms.
* Epidemiological areas: are defined as countries and territories that have confirmed cases of COVID-19 transmitted domestically, or where there is an active outbreak in Vietnam according to the “Interim guidance for surveillance, prevention and control of COVID-19” provided by the Ministry of Health and updated by the General Department of Preventive Medicine.
** Close contact: Includes
- Being in contact at health establishments, including: Directly providing healthcare for a confirmed COVID-19 case; working with health staff who is infected with COVID-19; visiting or living in the same room with a confirmed COVID-19 case.
- Being in direct contact with a distance of up to 02 meters with a possible or confirmed COVID-19 case during the illness.
- Living in the same house with a possible or confirmed COVID-19 case during the illness.
- Being in the same teamwork or office with a possible or confirmed COVID-19 case during the illness.
- In the same group of travel, business, entertainment, party, meeting, etc. with a possible or confirmed COVID-19 case during the illness.
- Traveling in the same vehicle (sitting in the same row, in front or behind 02 rows of seats) with a possible or confirmed COVID-19 case during the illness.
2.2. Confirmed case
Means the possible case or any person having a positive test with SARS-CoV-2 virus that are carried out by testing establishments permitted by the ministry of Health.
3. Preventive principles of infection in medical examination and treatment establishments
- Apply standard precautions combining with prevention of contact transmission and droplet transmission in examination and care provided to COVID-19 confirmed or suspected patients.
- Apply measures to prevent airborne transmission when performing aerosol procedures on SARS-CoV-2 confirmed or suspected patients.
- Good control of ventilation and environment, hand hygiene, and sufficient wearing of personal protective equipment are the most important measures to prevent infection to healthcare workers.
4. Measures to control transmission in medical examination and treatment establishments
4.1. Standard precautions
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 SARS-CoV-2 confirmed patients in emergency room, isolation ward or isolation room with sufficient special emergency means.
+ Arrange non-severe patients in a separate room or a group of the same condition may be arranged in the same room.
+ A SARS-CoV-2 positive test (+) patient must not be arranged with SARS-CoV-2 suspected patients.
4.2. Transmission-based precautions
4.2.1. 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 adequate personal protective equipment when entering 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.
- Remove gloves, gown and hand hygiene before leaving the isolation chamber. After putting off gloves and having hand hygiene, hands must not touch any surface of environment or things in the anteroom.
- Patient transportation out of the isolation room 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.
- Instruments and equipment used in examination, diagnosis, treatment and care of patients: 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.
4.2.2. Droplet precautions
Droplet precautions require the following contents:
- The patient must be arranged in a separate isolation room. If there is no separate room, this patient should be arranged in the same room with patients of the same pathogen but must keep a minimum distance of 02 meters.
- Wearing medical masks, goggles or face shield, especially when in close contact with the patient.
- Patient transportation out of the isolation room must be minimized. In case of transportation, the patient must wear medical mask, use the special pathway to avoid infection to other healthcare workers, patients and people.
4.2.3. Airborne precautions
The measures to prevent airborne transmission include:
- The patient must have a separate isolation room. In case there is no separate room, it is recommended to arrange the patients in the same confirmed infection 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. The patient must wear medical mask when getting out of the room.
- Procedures must be performed in a separate room with its doors tightly closed, with safe ventilation and far apart from other patients.
- When performing invasive procedures for SARS-CoV-2 confirmed or suspected patients, healthcare workers must wear sufficient personal protective equipment. In case of need for surgery or a sterile procedure, healthcare workers must wear sufficient personal protective equipment inside sterile gown.
- Cases that require mechanical ventilation, intubation, and continuous positive airway pressure (CPAP) also require wearing sufficient personal protective equipment (Mask N95, etc.) to prevent airborne transmission and droplets.
- In case of sputum sucking prescription, tools and non-open sputum sucking method must be applied to a patient in mechanical ventilation.
4.3. Environment control
4.3.1. Environment of surfaces of floors, walls, corridors
Environment control is the important measure to prevent SARS-CoV-2 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 0.1% active Chlorine (Refer details in the section of Cleaning and Disinfecting surfaces in environment).
4.3.2. 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 12 circulating airflow/hour.
+ The room where aerosol-causing procedures are performed must have proper room ventilation (≥ 12 circulating airflow/hour).
4.3.3. 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.
4.4. 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 SARS-CoV-2 confirmed or infected patient should have self-isolation and monitor body temperature within 14 days. It is required to 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, cover the mouth and nose with the 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.
4.5. Integrated precautions
- Many measures of infection control must be combined, including the process of triage, isolation, environment hygiene, waste management, proper use of process of personal protective equipment; control of infection in transportation, operation and treatment of corpse, control of infection in laboratories.
- Periodically assess the practice of SARS-CoV-2 infection prevention and control in medical facilities. Refer details in the inventory table in Appendix 18.
5. The task to prevent and control SARS-CoV-2 infection
Medical facilities should strictly execute the regulations on prevention and control of epidemic spread enacted by Ministry of Health.
All resources must be mobilized to control SARS-CoV-2 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:
5.1. 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 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 SARS-CoV-2 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.
5.2. Conditions and means
5.2.1. Hand hygiene means
Soap, alcohol-based hand hygiene solution, tissue or disposable hand tissue must be available at all necessary places.
5.2.2. Personal protective equipment
Anti-epidemic gown, apron, paper hat, medical mask, N95 mask, goggles (or face shield), boots, shoe-cover, medical gloves and hygiene gloves.
5.2.3. 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.
- Air disinfection filter.
For high effectiveness of SARS-CoV-2 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.
5.2.4. 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.
5.2.5. Isolation room
- The hospitals must arrange standard isolation wards or isolation rooms as regulated and must always be available for epidemic situation.
- Other medical examination and treatment establishments must prepare wards (rooms) to receive and triage SARS-CoV-2 confirmed or suspected patients.
- Medical facilities receiving patients infected with SARS-CoV-2 should have available negative pressure operating rooms with standards such as anechoic chamber but with additional clean air intake.
5.2.6. Medications
Medication list is subject to the treatment protocol.
5.3. Assign responsibility execution
- The Directors, leaders of departments and relevant persons are responsible for the contents of activities on SARS-CoV-2 infection prevention at medical examination and treatment establishments.
- 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. Consolidate and strictly implement with the issued regulations on measures to prevent and control disease transmission, immediately overcome existing problems when unsafe risks in epidemic control are detected.
- The Directors of medical examination and treatment establishments are responsible for the allocation of budget and experts for regular activities in infection control. Medical examination and treatment establishments are required to have a backup budget for epidemic prevention and control.
5.4. Training
Medical examination and treatment establishments must establish the scheme and hold training courses to educate all healthcare workers at the establishments on SARS-CoV-2 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.
5.5. 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 SARS-CoV-2 infection or suspected patients who come for examination and hospitalization. Duly execute regulations in patient transportation in the hospital, department transfer, and hospital transfer ensuring safety of healthcare workers, transporters, other patients and the community.
- Ensure necessary conditions for the reception, treatment and organize prevention and isolation in the medical examination and treatment establishment.
- 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 guideline on prevention of infection when the patient died
Pay proper attention to other hospital-acquired infection related to the care of SARS-CoV-2 confirmed or suspected patients (lung infection, septicemia, urinary infection, etc.).
SEPARATION, RECEPTION, SCREENING AND ISOLATION OF SARS-COV-2 CONFIRMED OR SUSPECTED PATIENTS
1. Objectives
Screening of patients, relatives, visitors, and healthcare workers to early detect and isolate SARS-CoV-2 confirmed or suspected patients, thus preventing the risk of SARS-CoV-2 infection for healthcare workers, other patients and community.
2. Principles for execution
- Medical examination and treatment establishments should make scheme for the system to detect, triage, categorization, and management of SARS-CoV-2 confirmed or suspected patient right when they come and have examination. People with symptoms of respiratory tract infections (cough, fever, runny nose, sore throat, chest tightness, difficulty breathing, body aches), people with epidemiological factors (coming from the epidemic area, in contact with infected people or having risk, etc.) needs to be separately instructed, screened and examined.
- Medical examination and treatment establishments should make scheme for screening, triage of patients, family members, visitors and healthcare workers. Medical examination and treatment establishments should to create separate procedures for receiving, screening, examining, categorization, quarantining, and transferring hospitals for patient with symptoms of respiratory tract infections and patient with epidemiological factors starting right from the hospital gate.
- The medical examination and treatment establishment must execute measures to prevent and control infection strictly (standard precautions and transmission-based precautions).
3. Scope of application: All medical examination and treatment establishments.
4. Screening and isolation of SARS-CoV-2 confirmed or suspected patients
4.1. Preparation of infrastructure and means
- Arrange, establish the isolation ward and isolation room to meet the isolation requirement. Medical examination and treatment establishments should have a separate screening area/clinic for COVID-19 confirmed or suspected patient (based on the Guideline for Diagnosis and Treatment of SARS-CoV-2 due to the new Corona virus strain dated July 29, 2020 by the Ministry of Health) and isolation room after screening for SARS-CoV-2 confirmed or suspected patient.
- The areas of waiting, examination, procedures for the SARS-CoV-2 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.
- Personal protective equipment (Refer the Guideline 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 for environmental sanitation, waste collection and treatment, tools, linens, etc.
4.2. Administrative measures
- Establish an epidemic prevention and control Steering Committee.
- Establish the specific and detailed process to receive and treat patients in screening, detection and isolation of SARS-CoV-2 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 not come yet.
- Do the task of screening of all visitors of the hospital, including the patient, the patient's family, and visitors right at the hospital gate. Do the task of categorization upon patients as soon as they come to have examination of the medical examination and treatment establishments with the triage questionnaire, medical declaration.
- The diagnoses to early detect a SARS-CoV-2 infected or suspected patient according to the Guidelines on diagnosis and treatment of COVID-19, Decision No. 3351/QD-BYT dated July 29, 2020 of the Ministry of Health. When a suspected case is found, it must screen and isolate as soon as possible.
- 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 such as hand hygiene, wearing mask.
- In case the patient has only epidemiological factors and has no clinical symptoms: Contact the local Center for Disease Control for concentrated isolation.
- In the case of a hospital admitting SARS-CoV-2 confirmed patients: In the case of SARS-CoV-2 confirmed or suspected after screening: Immediately transfer to the isolation area for COVID-19.
- In case where a hospital does not admitting SARS-CoV-2 confirmed patients: In the case of SARS-CoV-2 confirmed or suspected after screening: Immediately transfer to a temporary isolation room waiting for transfer to a hospital admitting SARS-CoV-2 confirmed patients.
4.3. Steps of execution for streaming, screening, diagnosis
4.3.1. In case the hospital has 2 or more gates (Figure 2)
Step 1. At the hospital gate (Initial Screening)
- Arrange a single gate only for the reception of people with symptoms of respiratory tract infections (Layout example of gate 2). At the gate for people with symptoms of respiratory tract inflammation, a sign board must be arranged clearly stating: “Gateway is for people with cough, fever, runny nose, sore throat, chest tightness, shortness of breath, fatigue, and contact with SARS-CoV-2 confirmed or suspected people”
- Beside the gate, an additional sign with colored lights (for example, LED temple signs, box signs with lights inside) must be arranged making people can see clearly at night, or need lights to light normal signs.
- On the street, similar signs must be arranged at easy-to-see places, for example: “Directions for people with cough, fever, runny nose, sore throat, chest tightness, difficulty breathing, body aches", or “Gate for people with cough, fever, runny nose, sore throat, chest tightness, difficulty breathing , body aches 30 meters to the right, people coming from the epidemic area or having factors related to SARS-CoV-2 confirmed or suspected people without symptoms should contact the hot line, etc.”.
- Parking should be arranged at outside or at the gate area. Attention should be paid to adequate training for security guards and car keepers on guidance, reception and control of SARS-CoV-2 infection.
- At all other gates, a colored sign board must be arranged clearly stating: “People with cough, fever, runny nose, sore throat, chest tightness, difficulty breathing, fatigue, and people go through gate 2 or coming from the epidemic area or having factors related to SARS-CoV-2 confirmed or suspected people without symptoms should contact the hot line, etc.”
- A medical registration and declaration desk should be arranged at a well-ventilated place next to the hospital gate or lobby. Note: remind the patient to wear a mask or have masks provided to the patient. Alcohol-based hand sanitizer is required at the medical registration and declaration desk.
Step 2: Streaming the movement to the screening room
- A separate streaming should be arranged from the gate to the screening room. The separate streaming must be wired with red/yellow tape (with reflector), width about 0.8 meters - 1.2 meters. The tape should be placed at both sides (or one side if the path goes along the wall/fence). A sign board must be arranged that requires the person with the symptoms to walk inside the wired streaming.
The hospital must arrange at least a dedicated vehicle (if the traveling distance is long), a private wheelchair to transport the SARS-CoV-2 confirmed or suspected patient. Dedicated vehicles must be parked at a separate place with signs, not used for the transportation of other patients and must be disinfected after each use.
Note: The arranged path does not pass through other departments/rooms, minimizes passage along the corridor. The registration and medical declaration desk should be arranged as close to screening area as possible.
Step 3: Screening area
- Screening room should be arranged at an isolated, well-ventilated location, separate from other departments/rooms (for example, erecting an aluminum-glass kiosk at an isolated location such as the corner of the yard, the back of the building), ensuring isolation, and separate from other departments.
- There is only one examination desk in a room in the examination room, sorely one patient at the same time in the examination room.
- The examination desk should be equipped with sufficient examination tools, materials and equipment for infection control. There is only one examination desk in a room in the examination room. The examination desk should be equipped with sufficient examination tools, materials and equipment for epidemic prevention and control.
Step 4: Streaming the movement after the screening
Once the patient has been screened, if it is certain that there is no epidemiological factor or no COVID-19-related clinical symptoms, then guide the patient to a normal examination area. Similarly, in the normal examination area, if a suspect factor is found again (epidemiological factors and/or clinical symptoms), the patient must return to the screening room.
Step 5: Transportation to another hospital or COVID-19 treatment and isolation area
- After screening, if a SARS-CoV-2 suspected patient was detected, the hospital will transfer the patient to one of the following two locations:
+ Temporary isolation room in a hospital: In case of the facility is not assigned to accept COVID patients, transfer the patient to a temporary isolation area. Medical facilities need to contact the Preventive Health Centers/Centers for Disease Control and the nearest hospital that is tasked with accepting and treating COVID-19, ensuring no infection during hospitalization.
- The temporary isolation room should be located close to the respiratory examination room, minimizing the movement of patients.
- Medical facilities are not allowed to transfer patients to another hospital by themselves, immediately contact the direct management agency and the higher-level hospital for correct referral instructions, to ensure that they do not cross-infect other patients.
COVID-19 isolation and treatment area:
The hospital, assigned by the management authority to treat COVID-19, must arrange an isolation ward to receive patients. The isolation ward must comply with the instructions of the Ministry of Health on the principle of dividing into 3 types of patients to be placed in different rooms:
- Separate the suspected infected patients (with clinical symptoms of respiratory inflammation, take samples for testing, have no test results yet, monitoring disease progress).
- Isolate people with mild illness;
- Isolate people with serious illness (with underlying disease, severe respiratory symptoms, mechanical ventilation need, etc.)
Collect specimens for testing (can take place at the medical facility or another site).
In case of indication, patients are taken sample for SARS-CoV-2 at the isolation ward or temporary isolation room. Depending on the actual conditions of the hospital, samples can be collected at the respiratory department. The hospital contacts the Preventive Health Centers/Centers for Disease Control for sample taking or performs it on-site if it has been approved by the Ministry of Health to test for SARS-CoV-2.
Figure 2. Diagram of streaming, screening for a hospital with several gates
4.3.2. In case the hospital has only 1 gate (Figure 3)
Follow the same instructions as a hospital with 2 gates, however, the following points should be arranged differently:
-Sign boards must be arranged at the hospital gate showing directions to the registration, screening and streaming desk/room.
- The registration, screening and streaming desk/room should be arranged right next to the hospital gate, in the yard or the main hall, following the principles as close to the gate as possible. The registration, screening and streaming desk/room mustn't be arranged inside the main building, near other departments, rooms to minimize the risk of infection.
- Screening area should be located right next to the registration, screening and streaming desk/room (within 10 meters from the gate).
Note: In the case of a SARS-CoV-2 confirmed patient is found in the inpatient ward, the patient must be temporarily isolated in a temporary isolation room at the ward.
Figure 3. Diagram of streaming, screening for a hospital with only one gate
- 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.
- Patients and family members should be instructed to wear medical masks, minimize contact with others, practice good hand hygiene, use hygiene solutions, and disinfect the nasopharyngeal tract.
- A family member accompanying a SARS-CoV-2 infected or suspected patient should be considered to have exposed to SARS-CoV-2 and must also be screened to the end of monitoring time as regulated to help early diagnosis SARS-CoV-2.
- 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.
4.3. 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 SARS-CoV-2 confirmed or suspected case must immediately give notice to the following persons:
+ Patient and family members.
+ 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.
- People in close contact with infected people must be listed and be under healthcare monitoring within 14 days after the last time of being in 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 SARS-CoV-2 confirmed or suspected patients. If there is any symptom, it must immediately be reported to the nearest medical facility for timely diagnosis and treatment.
- All emergency cases, patients with unknown risk factors are considered as SARS-CoV-2 suspected patient and the healthcare worker must wear adequate personal protective equipment as when they contact with SARS-CoV suspected patient.
4.4. Reception and isolation
- Zoning the risk and streaming the movement of SARS-CoV-2 confirmed or suspected people in the hospital are as follows:
+ The high risk zone (red color) comprises of the departments receiving and treating SARS-CoV-2 confirmed or suspected patients (for example: isolation ward; Outpatient department; Emergency and Resuscitation Department, Infectious Disease Department, Laboratory, etc.).
+ The medium risk zone (yellow color) 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 color) comprises of the departments less likely receiving, examining and treating SARS-CoV-2 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 SARS-CoV-2 confirmed or suspected patients.
5. Screening for inpatients, caregivers, and healthcare workers
5.1. Screening for inpatients and caregivers
- Priority departments should screen inpatients first: Intensive care; Respiratory; Infectious Disease; Hemodialysis; Geriatrics; Mental, Oncology Departments.
- It is necessary to screen for inpatients, family members taking care of patients who are hospitalized every day and hospital service providers.
- Strengthen monitoring; indicate early testing of SARS-CoV-2 for inpatients, patient's relative with suspicious manifestations, including cases with unclear epidemiological history for early detection and implement isolation in a timely manner.
- Strengthen monitoring of inpatient, take samples for SARS-CoV-2 when the patient has symptoms of serious viral pneumonia, severe acute respiratory infections, flu syndrome, even those inpatients for more than 14 days have rapid, severe, clinically inexplicable pneumonia, dialysis patients.
- The time of sample collecting must be implemented following the Guidance on temporary monitoring and prevention of COVID-19 (Attached to the Decision No. 3468/QD-BYT dated August 07, 2020 of the Ministry of Health).
- During the epidemic in the community: Minimize family members of a patient to care for another patient, in case of really necessary leaving only for a permanent family to care for the patient. Implement medical reporting, control compliance with regulations on infection prevention and control of caregivers. Stop the visiting from the inpatient's relatives.
- Requiring and instructing patients, caregivers and service providers to wear masks, hand hygiene, perform spacing right after entering the medical examination and treatment establishments and during their stay at medical examination and treatment establishments.
- In identified and operating outbreaks, all suspected cases are considered clinical cases and all measures for isolation, prevention and control of the epidemic must be implemented as well as information, timely report.
5.2. Screening for healthcare worker
- Strictly implement with regulations on social distance in hospitals between departments, rooms and groups of healthcare workers.
- Proactively assess the risk of infection among healthcare workers, service providers who have direct contact with SARS-CoV-2 confirmed or suspected patient, people who have returned from epidemic zones or have several symptoms such as fever, respiratory tract inflammation for early detection, and appropriate isolation according to regulations.
Refer details the inventory of the risk assessment of SARS-CoV-2 infection of the healthcare worker in Appendix 12.
- Make a list and monitor all healthcare workers exposed to SARS-CoV-2 according to regulations of the Ministry of Health (Refer details in prevention of SARS-CoV-2 infection for healthcare workers).
6. Inspection and surveillance
The Steering Committee for Prevention of the Diseases should develop a plan to monitor the screening and streaming of isolation. Assign departments, individuals and focal points to supervise the participation responsibility of related departments and individuals, build monitoring processes and tools. Monitoring content includes streaming, screening, use of personal protection equipment, implementation of procedures to prevent infection of SARS-CoV-2. Implement daily monitoring during the epidemic outbreak in the community:
- The Department of Infection Control shall be responsible for inspection and supervision of SARS-CoV-2 infection control implementation; also act as the focal point to build the isolation screening process.
- The General Planning Department combines with the Infection Control Department monitor, make statistics, give timely notice about the number of SARS-CoV-2 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.
- Departments coordinate to report monitoring results and propose solutions to improve gaps in screening and isolation.
The inventory used in evaluating the practice of prevention and control of SARS-CoV-2 infection by medical examination and treatment establishments is reference details in Appendix 18).
ESTABLISHMENT OF ISOLATION ROOM/AREA
COVID-19 is a very highly infectious disease. The early isolation upon a SARS-CoV-2 confirmed or suspected patient plays a very critical role. To execute well the isolation measures, the medical examination and treatment establishments must always have isolation ward and isolation room with full equipment. Healthcare workers must be trained in compliance with technical procedures in isolation.
Depending on the tasks, medical examination and treatment establishments set up isolation models in accordance with regulations.
- The Outpatient Department, Emergency Department, Intensive Care, Pediatrics Department, Infectious Disease Department must prepare an isolation room with full of necessary equipment to opportunely isolate patients if necessary.
1. Objectives
- Limiting and controlling the infection of SARS-CoV-2 in the medical facility environment and for the community, especially healthcare workers, patients, patients' family members and visitors.
- Prevent and control infection inside and outside the isolation ward.
2. Principles for isolation ward establishment
- For hospitals assigned to accept the treatment of SARS-CoV-2, isolation ward must be built according to regulations.
- For facilities not assigned to accept treatment: A temporary isolation ward/room is required at the screening area.
- 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.
3. Isolation ward design in medical examination and treatment establishments that accept COVID-19 treatment
3.1. Distribution of patient room
The rooms in the isolation ward include:
1) Administration chamber.
2) Patient-reception chamber.
3) Patient-treatment chamber for SARS-CoV-2 confirmed patient
4) Chamber for severe SARS-CoV-2 patients of emergency (having full emergency means and treatment used individually for each patient).
5) Patient-retaining chamber for SARS-CoV-2 suspected patient.
6) Tool-treatment chamber having all equipment for initial disinfection such as 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 shower, hand wash soap.
All rooms in the isolation area must have hand wash basins, disposable paper/towels, surface wipes, alcohol-based hand hygiene solution, and hand soap. The pathway must be from the low-risk to the high-risk infection area.
3.2. Ventilation system
- Ensure good ventilation, limit spread to other areas.
- A negative pressure room must have at least 12 airflow exchange every hour (ACH) and the negative pressure must be at least -3Pa.
- If this is not possible, natural ventilation should be applied. 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 at the end of the hallway, leeward, having 2-way convection windows opening towards a deserted place.
- In case of natural ventilation is insufficient, provide coordinated ventilation, forcing the air flow to go from the area of least risk to the area at highest risk (from the green area to the red zone) by means of an exhaust fan so that must have at least 12 airflow exchange every hour (Figure 4).
- Air released from the isolation ward must be disinfected with UVC or with combined method of disinfection and HEPA filtering.
Refer details in Ventilation control at COVID-19 patient consultation and treatment areas.
3.3. Isolation ward interior
- The floors and walls (with the minimum height of 2 meters) should be pressed with ceramic tiles for easy cleaning and disinfection.
- 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.
- The windows must be made from materials that are easily to be cleaned (glass, few items, easily to be washed and cleaned).
A: Disinfection place
B: Cabinet for personal protective equipment, clean linen and tools
C: Bag for after-used personal protective equipment, 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
The fan blows through the HEPA and UVC filtration systems, with air ducts blown upwards, at least 8 meters away from residential areas.
Note: Do not leave the absorbent carpet or the tray of chloramine solution in front of the isolation area/room for medical staff and patients to walk through because it does not work to prevent infection.
Figure 4. Diagram of isolation room for SARS-CoV-2 confirmed patient
4. Temporary isolation room, ward in hospitals do not accept and treat COVID-19 patients
- The isolation room and area should be located near the screening and emergency areas. The isolation room and area should be located outside of the inpatient area, far from other patients, deserted to admit SARS-CoV-2 confirmed or suspected patients.
- Isolation ward has isolation rooms, toilets, tool handling.
- Isolating room should have ventilation system as described above.
5. Patient bed arrangement in the isolation ward
- It is most preferable to arrange each SARS-CoV-2 confirmed patient in a separate isolation room (if possible).
- In case of not possible or if there are too many SARS-CoV-2 confirmed or suspected patients hospitalizing, the suspected patients may be arranged in the same room (group isolation), SARS-CoV-2 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 beds should be at least 2 meters.
6. List of essential things necessary at the isolation ward/room
- These things must always be available in the isolation ward, located on board or in the anteroom’s cabinet right in front of the isolation room or changing room.
- Those departments and units (such as environmental hygiene, waste treatment, patient transportation, etc.) related to the task of care and treatment of SARS-CoV-2 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 (Table 1). It is notable to have all sizes for users and the mandatory minimum number must always be available.
Table 1. Means and tools should be available at all times in the isolation ward/room
(Attached to the Decision No. 1259/QD-BYT dated March 20, 2020)
No. | Tools | Number |
| Personal Protective Equipment (PPE) | |
1 | Clean gloves of all sizes | 150 |
2 | Protective outfit | 30 |
3 | Eyeglass, face shield | 30 |
4 | Head hat | 50 |
5 | Boots or shoe-cover | 30 |
6 | N95 respirator | 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 solution holder | |
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 | |
7. Medical records in the isolation ward
- Optimal use of digital medical records or electronic devices to record information on examination, diagnosis, testing, treatment and daily monitoring of patients.
- In the lack of a digital medical record, the paper medical records are kept in the administrative office of the isolation ward, not in the patient room. Doctors and nurses perform oral orders by according to regulations or take notes on scrap paper, tablets and then transmit them out through the Internet, glasses, etc. This information is externally typed or recorded in medical records and then signed by the doctor or nurse in charge of the operation in the administrative office after personal protection equipment has been removed.
- Do not bring medical records from the isolation to the outside area. When needing consultation, the department captures the necessary medical records and sends it via electronic device (via email, etc.) to outside for consultation (online consultation).
- When needed for testing: X-rays, ultrasound, biochemical tests, all requests are sent to clinicians' request and test results are returned online and then printed in isolation ward. After that, the results must be pasted on the patient's medical record to save.
- All the designation cards and paper results used to record temporary information in the isolation ward after being copied, signed for pasting in the medical record must be cut, collected and processed as infectious waste.
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 (droplets or aerosol) carrying infectious pathogens of patients. Personal protective equipment is also used to protect patients, patients' relatives, visitors from being infected with pathogens from healthcare workers and the hospital environment. Carrying personal protection equipment according to instructions when taking care of patients is one of the most important measures to prevent infection of SARS-COV-2 for healthcare workers, patients and the community.
1. Objectives
To prevent the risk of SARS-CoV-2 and other pathogens infection from patients to healthcare workers, other patients and visitors, and the spread to the environment surrounding patients and the community
2. Scope of application
All healthcare workers, patients’ relatives, visitors, people having contact with confirmed or suspected SARS-COV-2 patients or specimens, instruments, cloth, waste, care tools or transports for confirmed or suspected SARS-COV-2 patients.
3. Principles for execution
3.1. General principles
- Use personal protective equipment as recommended by standard precautions combined with transmission-based precautions suitable to the situation in care and treatment of confirmed or suspected SARS-COV-2 patients.
- Personal protection equipment must be of sufficient size and meet quality standards according to the Decision No. 1616/QD-BYT dated April 08, 2020 of the Ministry of Health.
- Ensure the availability of personal protection equipment in reception, screening, temporary isolation, isolation, treatment areas, anteroom of isolation rooms, laboratory, waste treatment areas and corpse management areas.
- It is necessary to comply with the instructions and procedures of putting on and taking off personal protection equipment.
3.2. Rules for using personal protective equipment
1) Always wear personal protective equipment specified according to each situation when contacting, examining, and taking care of confirmed or suspected COV-2 patients. See Appendix 3 for case-by-case use of personal protective equipment. Ensure personal protective equipment cover the entire body; do not wear 2 masks at same time. Prepare adequate personal protective equipment suitable to the situation to be implemented.
2) In case of emergency, but cannot exploit epidemiological factors of the patient, use personal protective equipment like for SARS-COV-2 confirmed or suspected patient.
3) The practice of putting on and taking off PPE must be done competently before taking care of infected or suspected SARS-CoV-2 patients and must be supervised by a trained member.
4) Avoid contacting or adjusting personal protective equipment worn while working in isolation rooms or areas. Do not wear and remove personal protective equipment in the same room. The room to wear personal protective equipment must be outside the isolating room.
5) Remove personal protective equipment immediately after exiting the isolation area. Putting on and taking off personal protective equipment must be done in the anteroom before entering and after leaving the isolation room. Do not wear personal protective equipment after contact with an infected person to other areas.
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 personal protective equipment, pay attention to the following principles:
- The outer surface of personal protective equipment has a high risk of contamination, thus turn the outside in and do not shake while taking off personal protective equipment.
- The front of personal protective equipment has a higher risk of infection than the back. Avoid touching the front of personal protective equipment.
- Mask should be removed last.
8) Personal protective equipment 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 lids.
9) The healthcare worker directly taking care of the patient or the staff performing other services related to a SARS-CoV-2 confirmed or suspected patient must be trained to use personal protective equipment well.
4. Types of personal protective equipment
4.1. Type of personal protective equipment
Medical examination and treatment establishments need to choose personal protective equipment in accordance with standards of epidemic prevention and control in the following documents: (1) Decision No. 1259/QD-BYT dated March 20, 2020 on List of essential personal protective equipment of a COVID-19 isolation and treatment ward, (2) Decision No. 1616/QD-BYT dated April 08, 2020 on provisional guidance on techniques, classification and selection of COVID-19 epidemic prevention and control clothing.
In fact, there are many types of personal protective equipment, 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 shield.
- Medical gloves.
- Hood caps (cover the entire head and neck).
- High-length shoes covers.
- Rubber boots.
Type 2: Type of jumpsuits, gown and cap:
- Coveralls, gowns and caps.
- High-length shoes covers.
- Waterproof aprons.
- Medical masks.
- N95 respirators.
- Goggles or face shield.
- 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 (Figures 5, 6).
- Medical masks must be qualified with TCVN 8389 or ASTM, 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, should not use powdered gloves.
- 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 5:Goggles | Figure 6: Face shield |
| | 
|
Figure 7:Types of mask |
| 
| 
|
Figure 8: Gowns and aprons |
Figure 9: Hood cap | 
Figure 10: Clothes worn beneath gowns |
| | | | |
4.3. Prepare adequate number of available personal protective equipment
- The preparation of personal protective equipment should be implemented every year and during an epidemic. The calculation principle is based on the actual job description of healthcare workers working in different departments and positions.
- Use a tool or method to monitor the quantity of used personal protective equipment and estimate the need of personal protective equipment (refer to Appendices 3-4).
- See the Decision No. 1259/QD-BYT dated March 20, 2020 on the List of essential personal protective equipment of a COVID-19 isolation and treatment ward in order to correctly estimate the number of personal protective equipment needed to suit the function, according to the estimation of the number of COVID-19 patients that can be received.
- Medical examination and treatments should develop guidance on the use of personal protective equipment for the right purposes, to avoid waste and inefficiency.
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:
- Perform 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 masks:
- Remove the mask strap, do not let hand touch the mask; discard the mask into the waste container as prescribed.
- Perform hand hygiene.
5.1.2. High filtration capacity mask (N95 Respirator)
* Technique to put on respirator:
- Perform 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): Breathe out strongly, if the respirator is tight, positive pressure causes the mask to slightly inflate. 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.
* 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.
- Perform hand hygiene.
5.1.3. Points to note when putting on and taking of masks
Figure 12. Take off N95 respirators
- 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 frame and the strap of the mask to ensure that the mask fits close to the bridge of the nose and face, not letting air in/out through the gap between the mask and the face.
- 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 (separated anti-epidemic suit)
Before wearing personal protective equipment, it is necessary to check the quantity, type and size suitable for the carrier; check the quality of personal protective equipment (according to specified standards, no tear, perforation, expiration, etc.), then take the following steps:
Step 1: Hand hygiene
Step 2: Wearing boots/shoes cover over the sleeve (inside).
Step 3: Put on pants and gown (wear apron if indicated).
Step 4: Wear a mask (Medical mask, or N95 as guidance above).
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: Hand hygiene
Step 9: Wear gloves as indicated
5.3. Order to take off personal protective equipment
Personal protective equipment should be removed in the buffer room, and placed in an infectious waste collection bin after disposal. Always practice hand hygiene when removing every personal protective equipment.
Figure 13: Procedures for removing personal protective equipment
5.3.1. Type of detached pants, gown and cap
Step 1: Roll the inside out when removing gloves, then put them into waste container. (In case of wearing apron, hand hygiene before 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).
Figure 14: Removing gloves
Note:
- With normal care (such as measure body temperature check pulse, blood pressure, intramuscularly, intravenously, etc. or doing operations that do not require elasticity, friction and not easily tearing gloves) only wear 1 glove.
- When surgery, invasive procedures (laparoscopy, delivery, tracheostomy, endotracheal intubation, etc.) and taking samples for testing, autopsy should wear 2 gloves.
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 the pants and shoe covers at the same time, during the removal process always wrap the inside of the pants out, ending up in the waste bin. If wearing boots, boots should be removed first, placing them in a container with antiseptic solution, then hand hygiene before removing the pants as above.
Step 6: Hand hygiene
Step 7: Remove cap by slipping hand into the cap
Step 8: Remove the goggles (for goggles with headband inside the hood cap).
Figure 15: Remove goggles and mask
Step 9: Hand hygiene
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. Remove gloves, roll the inside out and put it into waste container. In case of wearing apron, hand hygiene before 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 goggles or face shield (with elastic strap outside the hood cap)
Note: For goggles with headband inside the hood cap, remove the cap before removing the glasses.
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 shoe covers, turn inside out and put in waste bin. 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 personal protective equipment at the anteroom of isolation rooms and areas.
5.4. Procedures for wearing personal protective equipment when taking samples of hydrophobic fluid (throat swab, endotracheal fluid)
5.4.1. Type of personal protective equipment using in sample colleting
- Anti-epidemic disposable clothes.
- Waterproof cape.
- Hood or cape covering head and neck with waterproof material.
- Respirators mask (N95, equivalent)
- Goggles or face shield.
- Clean, powder-free medical gloves
- Rubber boots/waterproof boots with high neck.
Table 2: Regulations on personal protective equipment wearing in the SARS-CoV-2 examination.
Table of regulations of personal protective equipment wearing at the sampling, storage and transport of test samples outside of medical examination and treatment establishments |
| Subjects | Manipulation of implementation | Protection level |
Mobile sampling rooms | Technicians, healthcare workers | Manipulation of respiratory sample collection | Level 4 |
Technicians, healthcare workers | Preservation and transportation of samples | Level 2 |
Rooms for taking samples and handling samples at other medical facilities (CDC centers, research institutes, etc.) | Technicians, healthcare workers | Manipulation of respiratory sample collection, practice of testing suspected samples, samples of COVID-19 confirmed patients | Level 4 |
5.4.2. Wear and remove personal protective equipment during sample collection process
a) Personal protective equipment wearing order
* In case of using 2 pairs of gloves:
- Step 1: Hand hygiene
- Step 2: Wear the gloves 1
- Step 3: Wear coveralls and boots.
- Step 4: Wear masks and goggles
- Step 5: Wear caps and face shields
- Step 6: Wear the gloves 2 (covering the sleeve)
b) Personal protective equipment removing order
* In case of using 2 pairs of gloves:
- Step 1: Remove the gloves 2 (outside)
- Step 2: Remove face shields and caps
- Step 3: Remove coveralls and boots
- Step 4: Remove the gloves 1 inside), hand hygiene
- Step 5: Remove goggles and masks
- Step 6: Hand hygiene
Note:
- In case of inside microbiology department, personal protection equipment should be removed outside of the microbiological laboratory.
- In case of on the field, it is necessary to have a room or area to remove and put in the waste container, chemicals should not be sprayed into the personal protective equipment in use.
- Do not disinfect alcohol outside gloves.
- After removing gloves 1, hand hygiene
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 surveillance:
+ Personal protective equipment is available all the time at the anteroom of isolation rooms and areas.
+ Healthcare workers use the necessary personal protective equipment adequately and properly.
+ Used personal protective equipment 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 SARS-CoV-2 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 examination and treatment establishments must:
1. Hand hygiene equipment
Fully supplement hand hygiene facilities at all areas with people infected or suspected of SARS-CoV-2.
1.1. Hand hygiene equipment with soap and clean water
- 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.
Figure 16. 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 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, 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.
- 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)
1. | Before contacting patient | 
|
2. | Before performing aseptic procedures |
3. | After blood and body fluid exposure |
4. | After touching patient |
5. | After touching patient surroundings |
Figure 17. Moments of hand hygiene when taking care of patient
- 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 and immediately after removing 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 18)
- 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 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. Wash your hands under running water.
Figure 18. Hand hygiene techniques with soap and clean water
3.2. Hand hygiene with alcoholic solution (Figure 19)
- 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.
Figure 19. Hand hygiene techniques with alcoholic solution (20-30 seconds)
Notes:
- Clip fingernail short.
- Remove all jewelry on your hands (ring, bracelet, watch, etc.).
- The techniques of hand hygiene are similar to the ones with soap and water. Rub at least 5 times each step.
See also Instruction on hand hygiene in health facilities issued under the Decision No. 3916/QD-BYT dated August 28, 2017 by the Minister of Health.
HANDLING OF MEDICAL INSTRUMENTS
All equipment used for the care and treatment of a person infected or suspected of SARS-CoV-2 are potentially infectious, and if not handled properly, they will spread and infect healthcare workers and communities.
1. Objectives
Help the health-care worker recognize the risk of infection caused by tools and strictly follow the steps in the process of handling the device after using it on SARS-CoV-2 suspected patients: cleaning, disinfection and sterilization ensure safety for patients, healthcare workers and the community.
2. Principles
- The following tools used for the patient must be disposed of at the arising place in accordance with regulations.
- The specialized medical equipment and instruments used for patient care and treatment are ideally disposable. The reusable tools must be handled in accordance with the Ministry of Health regulations.
- All disposable medical equipment and instruments but handled for reuse must be cleaned and disinfected in accordance with the manufacturers' instructions and the Ministry of Health’s regulations.
- Specialized medical equipment and tools are treated, disinfected and sterilized according to the proper process and functional assurance.
- The process of guiding disinfection, sterilization of tools and facilities for patient care is always sufficient at the tool handling place.
- Tools, chemicals, consumables, personal protective equipment must always be available and ready for use.
- Staff working on disinfection and sterilization must be trained and have a certificate of training in disinfection and sterilization.
- Quality control and inspection of all types of tools must be strictly carried out at all stages of the tool handling process.
- Make statistics and report on the handling and provision of care and treatment instruments for people with confirmed or suspected SARS-CoV-2.
- People involved in handling tools must be instructed to prevent infection according to the regulations and their names should be recorded on a list.
3. Subjects and scopes of application
3.1. Subjects of application
- Persons handling medical instruments (in isolation area, clinical unit, subclinical area related to care for people with confirmed or suspected SARS-CoV-2 and central sterilization units).
- Healthcare workers who directly provide care at the treatment and care units for people with confirmed or suspected SARS-CoV-2.
3.2. Scope of application
- Isolation room/ward
- Central sterilization units/Department of infection control.
- Areas of receipt, classification and visiting for people with confirmed or suspected SARS-CoV-2.
4. Tools
4.1. Sterilization and disinfection facilities
- Personal protective equipment according to level 3 standards: (1) mask, (2) elbow-length rubber gloves, 450 cm - 500 cm in length, (3) anti-epidemic suit including cap, coverall (4) face shield, (5) shoe cover, (6) boots (designated areas).
- Containers for soaking tools, with lids, of a capacity suitable for all types of tools (color code and private label regulations stating that containers of tools are suspected to contain SARS-CoV-2).
- Instrument washing sink (made of easy-to-clean and disinfect materials).
- Instrument washer.
- Steam sterilizer, drying cabinet.
- Low-temperature sterilizer (EO, Plasma, etc.).
- Water source.
4.2. Chemicals
- Cleaning solution: detergents/disinfectants containing enzymes or other cleaning chemicals.
- Medium level disinfectant solution:
+ Chlorine compounds: Presept, Javel, Chloramin B, etc.
+ Compounds containing alkylamine
+ 70° alcohol (used to rinse the endoscope after completing the procedure).
+ Or other medium-level disinfectants.
- High-level disinfectant solution: glutaraldehyde ≥ 2%, orthophthaldehyde 0.55%, Peracetic acid 0.2-0.35%, Hydrogen peroxide 7.35% + 0.23% Peracetic acid, etc. or other high level disinfectants (Refer details in the Decision No. 3916/QD-BYT dated August 28, 2017).
4.3. Water: Clean water, sterile water.
5. Implement handling for each group of instruments
5.1. General measures
- Transfer all tools to the central sterilization treatment area of medical facilities after initial handling. Treatment should not be organized in the isolation as the establishment of a high-level disinfection treatment area requires time and investment in personnel, infrastructure as well as a variety of facilities and equipment.
- In case it is not possible to immediately transport tools after use, place the tool in a closed container with a lid and spray enzyme solution to prevent the tools from drying and organic matter coagulation before transport, moved to a central sterilization treatment area.
- In the isolation ward, a separate room/area with sufficient means to gather and pack tools prior to transport should be arranged.
- It is recommended to pack 2 layers, outside the package labeled "Instruments at risk of SARS-CoV-2 infection" before being put in boxes for transport to the central sterilization treatment unit.
- The isolation ward should arrange a buffer zone with the function of delivering and receiving tools (including dirty fabrics, wastes, personal protective equipment) that need to be treated.
- Implementation personnel must be trained in the steps of handling, packaging, safe transportation of tools, using personal protective equipment, transmission routes and measures to prevent transmission of SARS-CoV-2.
- Instruments from the isolation ward should be transported to the central sterilization treatment area following to a fixed route that has been established in accordance with the principle of prevention of transmission of SARS-CoV-2 (separate, with warning signs); by sealed, labeled transport; by trained staff (should be the staff in charge of the central sterilization treatment unit).
- The central tool-handling unit should arrange its own personnel, area, equipment and means to receive and handle used tools from the isolation ward.
Before transporting tools, prior notice should be given to the sterilization treatment unit (by phone call) for good coordination in delivery and pick-up at isolation, transporting, and delivery - receipt at a central sterilization treatment area.
Figure 20. Diagram of the positions in the cycle of tool handling from the isolation ward
5.2. Other semi-essential things
Semi-essential tools include 2 main groups: (1) diagnostic endoscopy instrument group and (2) respiratory supporting instrument group
(1) For the group of respiratory supporting instrument:
- Should be used only once, after use is disposed of in accordance with regulations
- In case of reusing, must strictly comply with the procedure as recommended by the Ministry of Health (see instructions for sterilization in medical facilities according the Decision No. 3671/QD-BYT of the Minister of Health).
(2) For the group of diagnostic endoscopy instrument: The process must be strictly followed according to the manufacturer's recommendations and issued by the Ministry of Health (refer details in the Decision No. 3916/QD-BYT dated August 28, 2017).
(3) Chemicals:
- Chemicals for cleaning: the detergent contains enzymes
- High-level disinfectant chemicals: glutaraldehyde ≥ 2%, orthophthaldehyde 0.55%, Peracetic acid 0.2-0.35%, Hydrogen peroxide 7.35%+0.23% Peracetic acid.
Note: For chemicals to be used, comply with the manufacturer's regulations and instructions on concentration, immersion time, water temperature, formula (activated or not), and used time after activating/opening, compatibility with instrument and side effects if any. High-level disinfectant chemical solution must be tested to assess bactericidal potency every day.
Table 3. Several regulations/guidelines for the use of high-level disinfectants
Active ingredient name | Hydrogen Peroxide | Peracetic Acid | Glutaalde-hyde | Ortho-phtaaldehyde | Hydrogen peroxide Peracetic acid |
Concentration | 7.5% | 0.2% | ≥ 2.4% | 0.55% | 7.35%/0.23% |
Soak time and temperature for high-level disinfection | 30 minutes at 20°C | Unclear | 20-90 minutes at 20-25°C | 5-12 minutes at 20°C* 5 minutes at 25°C in washing machine | 15 minutes at 20°C |
Soak time and temperature for sterilization | 6 hours at 20°C | 12 minutes at 50-56°C | 10 hours at 20°-25°C | No data | 3 hours at 20°C |
Activation | No | No | Yes | No | No |
Used time | 21 days | Use 01 times | 14-30 days | 14 days | 4 days |
Expiry date | 2 years | 6 months | 2 years | 2 years | 2 years |
Compatibility with instruments | Good | Good | Very good | Very good | Unclear |
Common effects | Eyes | Eyes | Respiratory | Eyes, skin | Eyes |
* According to US standards for 12 minutes, according to Asian standards: 5 minutes at 20°C. Refer details in the Decision No. 3916/QD-BYT dated July 28, 2017 of the Minister of Health.
5.3. Essential things
- Surgical instruments in clinical and surgical departments when performed for SARS-CoV-2 confirmed or suspected patient.
- The tools go into the sterile chamber, so they must be sterilized at a centralized sterilization unit and initially processed at the place they are used and then safely transported to the treatment area.
- Must comply with the procedure as recommended by the Ministry of Health (see instructions for sterilization in medical examination and treatment establishments according the Decision No. 3671/QD-BYT of the Minister of Health).
- Perform cleaning and disinfection at the department according to the process
+ Initial cleaning by enzymes
+ Then soak the instruments in a medium-level disinfectant solution.
- After the instruments are cleaned and disinfected at the department/unit, the instruments will be dried and packed and transferred to the central sterilization treatment unit.
5.4. Instruments that are unessential in departments/units
- A group of instruments in contact with healthy skin, not in contact with mucous membranes and damaged skin, low risk of infection, low level of disinfection requirements.
6. Cleaning and disinfection must be implemented after each use with common chemicals containing chlorine or alcohol at 70° or ammonium grade 4 as prescribed (see instructions on disinfection and sterilization in medical examination and treatment establishments attached to the Decision No. 3671/QD-BYT of the Minister of Health).
7. Implementation organization
7.1. At isolation room/area
7.1.1. Preparation
- Wear adequate personal protective equipment: (1) mask, (2) elbow-length rubber gloves, 450 cm - 500 cm in length, (3) anti-epidemic suit including cap, coverall (4) face shield or goggles, (5) shoe cover, (6) boots (designated areas).
- Preparation of instruments:
+ Materials and instruments used for packing tools.
+ Chemical enzymes in the form of aerosols.
+ Materials and instruments used for labeling.
+ Vehicles, boxes for transportation
7.1.2. Implementation procedures
- The following utensils used for the patient are initially cleaned with initial cleaning and disinfection chemicals, then placed in a clean lid/container and labeled “Instruments at risk of SARS-CoV-2 infection”, when transported to the outside, it will be put in a second bag/second box to be transported to a centralized sterilization treatment unit.
- In the absence of an initial treatment area at the place they are used such as screening room, operating room, or surgery, the following steps can be done:
+ Spray enzyme chemicals on instruments.
+ Packing 2 layers, yellow outer layer. Or an inner layer labeled “SARS-CoV-2 Hazardous Instrument” and 1 outer carton before transportation.
- Note: Make a call to inform the centralized sterilization unit of infection control before transport.
7.2. At the central sterilization unit
The reception area must be arranged and immediately handle instruments transported from the isolation area, giving priority to immediate or separate handling in order to prevent spread and infection in the area and to the other departments.
7.2.1. Preparation of facilities
- Arrange facilities and staff who separately handles instruments of people with confirmed or suspected SARS-CoV-2 in the isolation area if possible.
- The staff handling instruments must wear the personal protective equipment before handling of instrument: (1) mask, (2) elbow-length rubber gloves, 450 cm - 500 cm in length, (3) anti-epidemic suit including cap, coverall (4) face shield, (5) shoe cover, (6) boots (designated areas).
- Prepare all facilities and tools for cleaning and disinfection:
+ Instrument cleaning basin/instrument cleaner.
+ Chemicals.
+ Cleaning tools (brush, tube wiping stick, etc.)
+ Water source.
+ Multi-function instrument washer, cleaner and disinfecting machine (can wash various types of metal instruments and airway plastic instruments).
+ High temperature sterilizer for heat resistant tools.
+ Low temperature sterilizer for non-heat resistant tools.
7.2.2. Implementation procedures
- Case for manual cleaning and disinfection (without instrument washer and disinfecting machine):
+ The joints of instruments to be disassembled are opened and put into the trays, racks in accordance with the manufacturer's regulations.
+ Mix disinfectant chemicals as instructed (Appendix 11: Chemicals used in prevention and control of COVID-19 epidemic).
+ Immediately immerse instruments into disinfectant solution prepared in line with the prescribed concentration and time.
+ Clean tools with specialized brushes and brooms.
+ Scrub the tube, slots and interstitial tools.
+ Washing under running water (the first time)
+ Immerse instruments into disinfectant solution prepared in line with the prescribed concentration and time.
+ Scrub and clean tools under the water surface of the instrument soaking sink, gently brush the instruments to avoid splashing.
+ Washing under running water (the second time)
+ Dry the instruments (drying cabinet, wiping dry).
+ Move the tools to the packing area to follow the next steps of the process: Inspection, lubrication, labeling (kit name, packer, date of pack, expiry date), calibration tests (contact control indicator, package control) and transfer for sterilization.
- Clean and disinfect by specialized machine
+ The joints of instruments to be disassembled are opened and put into the trays, racks in accordance with the manufacturer's regulations.
+ Install the washing program of the machine (heat-resistant and non-heat resistant instruments).
+ Run the machine under the installed program.
+ At the end of the cycle, take the equipment out of the packaging machine as prescribed.
+ In case the washer does not have a drying mode: put instruments into the dryer or dry by wiping manually with clean, dry cloth before packing.
- Conduct the disinfection procedure (Depending on the method of application: high temperature/low temperature).
- Tools after sterilization must be stored and dispensed according to daily requirements like other common tools.
Note:
- After finishing work, the staff handling instruments in each area must remove the personal protective equipment and do hand hygiene before moving to another area.
- Clean the instrument handling area at the end of shift/working day.
8. Inspection and surveillance
- Heads of Department and Head Nurses should regularly inspect and monitor the strict compliance:
- Healthcare workers fully have facilities, consumables, chemicals and personal protective equipment when handling instruments.
- Monitor the cleaning, disinfection and sterilization procedures at the area with dirty instruments (consultation/isolation room, laboratory, etc.).
- Monitor the procedures for putting on/taking off the personal protective equipment of the healthcare workers working in areas related to these patients.
- Save the list of healthcare workers who handle instruments, regularly monitor, survey and detect signs of infection.
Refer details in the Guidelines on disinfection and sterilization in medical facilities attached on the Decision No. 3671/QD-BYT dated September 27, 2012 by the Minister of Health.
HANDLING OF EATING UTENSILS
1. Objectives
- Nutrition staff must follow proper food handling procedures, supply and handling of eating utensils for SARS-CoV-2 confirmed or suspected patients.
- Ensure safety for patients, healthcare workers and the environment in isolated areas and medical examination and treatment establishments.
2. Principles for execution
- All utensils used for living, eating and leftover food of people with confirmed or suspected SARS-CoV-2 are potentially infectious and need to be treated like infectious waste. They must not absolutely be used for other purposes (watering plants, raising cattle, poultry, etc.).
- It is ideal to use disposable utensils and then collect, transport and destruct them immediately after use as infectious medical waste.
- In the absence of disposable utensils, the reuse of used utensils must strictly follow the disinfection of reusable utensils like the disinfection and sterilization procedures for care and treatment instruments used for people with confirmed or suspected SARS-CoV-2.
3. Subjects and scopes of application
SARS-CoV-2 confirmed or suspected patients, healthcare workers, or nutrition staffs directly taking care of SARS-CoV-2 confirmed or suspected patients.
4. Tools
- Personal protective equipment to prevent infection from contact.
- Sink/lavabo, soap.
- Buckets, containers of disinfectant solution with anti-evaporation lids.
- Chemical disinfectant prepared with exact concentration of 0.1% (500 ppm) active chlorine.
5. Procedure
5.1. Use disposable utensils
- After persons with confirmed or suspected SARS-CoV-2 eating or drinking, their eating or drinking utensils and leftover food must be put into infectious waste container in isolation room according to instructions for infectious waste disposal.
- Sanitation workers collect and treat this waste as infectious medical waste.
5.2. Use reusable utensils
- Healthcare workers must instruct SARS-CoV-2 confirmed or suspected patient to put their utensils after use into the reusable utensil container.
- Healthcare workers collect the reusable utensils and put them into closed container with label of eating utensils of SARS-CoV-2 confirmed or suspected patient and then move them to the Department of Nutrition (or Department of Infection Control) for properly handling.
- The liquid from leftover food, water will be collected as infectious waste of the isolation area properly and decontaminate by boiling before being transported to the treatment place.
- Transport the reusable tools to the centralized handling area, store in bags, containers with lid. Do not carry it in your arms and on shoulders with bare hands.
- Soak to disinfect food and drink containers after use in a solution of 0.1% active chlorine active ingredients for 10 minutes-20 minutes. It is required to completely immerse such utensils in disinfectant solution. In the absence of disinfectant chemicals, the tools can be boiled for 10 minutes before washing them to reuse.
- Encourage the use of automatic utensil washing machines with closed doors and operation with chemical and temperature cycles, then automatic drying for different types of utensils (including many different types) for SARS-CoV-2 confirmed or suspected patient.
Note: When handling the eating or drinking utensils, staff should wear person protective equipment as instructed.
6. Inspection and surveillance
Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with the procedures:
- Surveillance over procedures for use of personal protective equipment when handling the reusable utensils.
- Surveillance over procedures for collection, transportation, handling and reuse.
Refer details in the Guidelines on disinfection and sterilization in medical facilities attached on the Decision No. 3671/QD-BYT dated September 27, 2012 by the Minister of Health).
LINEN HANDLING
1. Objectives
- Healthcare workers must comply with the linen handling procedures of persons with confirmed or suspected SARS-CoV-2.
- Ensure safety for patient, healthcare workers, patient families, visitors and community.
2. General principles and regulations
- Collect all linen at the place where dirty linen is discarded. - Do not shake, dump or count linen collected from the process of care and treatment of persons with confirmed or suspected SARS-CoV-2 at the place where dirty linen is discarded.
- After being collected at isolation, triage, treatment, examination, diagnosis area related to COVID-19, linen must be contained in 2-layer bags that are tightly packed, must not be torn, punctured, and impermeable with label "POTENTIAL SARS-COV-2 LINEN". Such linen must be transported immediately to the laundry house by dedicated means and must be washed immediately and separately without soaking, storing, counting or classifying dirty linen. These bags shall be handled as infectious waste.
- Staff collecting, transporting and handling dirty linen must follow the procedures for wearing and removal of protective equipment in accordance with the instructions. Comply with hand hygiene, remove gloves after transporting dirty linen.
- Wash linen with machine at high temperature (about 60-70°C) and disinfectant with chlorine compounds. In the absence of a washing machine, handwashing of line is required. Soak the linen in disinfectant before washing with an active chlorine concentration of 0.01% - 0.1% depending on the degree of contamination of blood and fluids (see Appendix 11).
- Wash and dry or naturally dry linen in line with procedures for infectious linen handling.
- A laundry house must satisfy requirements for prevention of SARS-CoV-2 transmission such as:
+ Be one-way laundry house.
+ Have a system of wastewater treatment.
+ Its staff must be trained.
+ Have enough standard personal protective equipment.
- In case a hospital outsources a laundry service provider: Ensure that such provider meets all condition for infectious linen handling, has the legal person status and is appraised and granted by a competent state agency license for laundry service meeting safety conditions for prevention and control of SARS-CoV-2 transmission.
3. Subjects and scopes of application
3.1. Subjects of application
- Staff of a laundry house/company and staff collecting and transporting linen.
- Staff in a procedure room, operating room, isolation ward or isolation room or COVID-19-related patient reception place.
3.2. Scope of application
- Procedure room, technical room, patient room, isolation room, COVID-19 isolation and screening area.
- Laundry houses handling linen related to COVID-19.
- Other areas related to linen of persons with confirmed or suspected SARS-CoV-2.
4. Vehicles
- Washing machine with washing mode at temperature of 60°C-70°C, dryer maintaining the temperature of 80-90°C.
- Yellow non-perforation bags, with lace and symbol for high-risk infectious linen (COVID-19 patient linen), yellow containers, separate infectious linen transporting vehicles.
- Personal protective equipment for collecting, transporting and washing staffs.
- Washing chemicals: Soap, detergent, disinfectant (Javel, Cloramin B, etc.).
- Clean and dirty linen transporting vehicles.
5. Implementation
5.1. At patient room/isolation room/procedure room/technical room
- Staff collecting dirty linen must wear prescribed personal protective equipment before tasks and do hand hygiene, remove gloves, personal protective equipment properly after finishing work.
- Linen in operating room, delivery room, patient room/isolation area must be collected into waterproof yellow bag put in container with lid and tightly tied before being transported to the laundry house.
- Disposable linen: Gowns, caps, masks, shoe covers are all put in a yellow bag, and placed in a container with lid and tightly tied to the top of the bag when being transported to infectious medical waste storage for destruction.
- All bags of linen when moved out must be put into another bag and then moved to the laundry, the bag labeled "POTENTIAL SARS-COV-2 LINEN".
- Laundry staff shall come to pick up the linen at the scheduled time or unexpectedly on request.
Medical facilities to be assigned to reception, treatment of COVID-19 patients must fully meet conditions for laundry service for medical examination and treatment activities.
5.2. At laundry
- After collecting linen to the laundry house, immediately put them into the washing machine and washed by chemical or soap washing mode at the temperature of 60°C-70°C. Soak linen of people with confirmed or suspected SARS-CoV-2 in a chemical solution containing 0.01% -0.1% of active chlorine depending on the degree of contamination of linen for at least 10 minutes before washing (soak in machine). Dry the linen or naturally dry linen in a private, sunny place, and iron the linen.
- Collect the linen from COVID-19 patient area/room (-) to room to isolate and treat COVID-19 patients (+), put it in dedicated linen bags and immediately transport them to laundry area. Not count and classify dirty linen at the place where dirty linen of patients isolated for treatment of COVID-19 is discarded.
- Linen after being dried must be ironed, put into closed and dry cabinet and distributed to patients for use according to regulations.
Attention: If washing machine is not equipped, staff performing the manual washing procedure must strictly adhere to regulations, wear personal protective equipment during washing and after finishing work, put off personal protective equipment and do hand hygiene.
Delivery and receipt of dirty linen shall be performed at anteroom, dirty corridor of operating, procedure area.
5.3. Linen storage and dispensing
- Linen used for people with confirmed or suspected SARS-CoV-2 must be stored in closed cabinet or be put on clean shelf in storage and used by quantity and types according to demand of patients and medical professional activities.
- The list of linen of operating rooms, delivery rooms, procedure rooms, isolation areas, consultation rooms for people with confirmed or suspected SARS-CoV-2 must be notified to the laundry.
- A base number of clean linen (at least a triple base number) must be stored in the isolation area for daily use.
6. Inspection and surveillance
- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with dirty linen handling procedures (from classification, collection, transport, handling).
- Medical examination and treatment establishments outsourcing laundry for SARS-CoV-2 examination and treatment are responsible for inspection of laundry and for prevention and control of transmission at laundry establishments according to current regulations.
- Content of surveillance:
+ Procedures for use, collection, transportation and handling of infectious linen.
+ Facilities for dirty linen handling (bag, container, transporting vehicle).
+ Procedures for instructions and techniques for linen handling.
+ Wash hands and clean instruments after finishing work.
+ Chemicals used in linen handling.
+ Personal protective equipment for healthcare workers.
+ Procedures for use of personal protective equipment of staff collecting, transporting and handling infectious linen.
CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES
1. Objectives
- Workers performing environmental cleaning must understand instructions, regulations on, procedures for environmental cleaning in the reception, screening and isolation areas for people with confirmed or suspected SARS-CoV-2.
- Strictly follow the environmental cleaning procedures in the reception and treatment area for people with confirmed or suspected SARS-CoV-2.
- Cut off the SARS-CoV-2 transmission routes by contact.
- Ensure the safety for patients, health workers and communities.
2. Principles of implementation
The surface of the screening and isolation area for people with confirmed or suspected SARS-CoV-2 must be cleaned and disinfected as per the following principles:
- All surfaces in the screening, isolation and treatment areas with visible or unclear blood, secretions, waste from people with confirmed or suspected SARS-CoV-2 must be cleaned and disinfected at least 02 times a day and when needed (after examination, testing, procedures, spillage of blood and fluids, post-transfer/discharge, death).
- All surfaces (in the isolation area of people with confirmed or suspected SARS-CoV-2, including the surface of care instruments, transportation vehicles must be cleaned, disinfected with disinfectant chemicals licensed by the Ministry of Health).
- Healthcare workers when cleaning and disinfecting surfaces associated with people with confirmed or suspected SARS-CoV-2 should strictly follow the principles and techniques for surface cleaning and precautionary measures of transmission.
- Workers performing surface cleaning and disinfection of the environment in the treatment and isolation area of people with confirmed or suspected SARS-CoV-2 must be trained in procedures for surface cleaning and disinfection, proper and strict use of personal protective equipment when performing their duties.
3. Subjects and scopes of application
- All healthcare workers performing the environmental cleaning in all areas related to care and treatment of people with confirmed or suspected SARS-CoV-2.
- All surfaces of facilities and utensils related to patients, beds, cabinets, tables, chairs, toilets, etc. in screening, receiving area, isolation room, laundry, waste collection area, handling area of reusable instruments, transportation vehicles related to care and treatment of people with confirmed or suspected SARS-CoV-2.
4. Vehicles
- Personal protective equipment (see Use of personal protective equipment), for gloves: must use elbow-length rubber gloves. Use waterproof aprons when cleaning areas with water, rubber boots when cleaning toilets and areas with water, fluids.
- Procedures for implementation, instruction table for environmental cleaning and disinfectant chemical preparation on transportation vehicles.
- Hand washing soap.
- Prescribed cleaning and disinfectant chemicals preparation (it is possible to use the hand-held spray for surfaces difficult to wipe with cloth) with 0.1% of active chlorine, cloth impregnated with disinfectant solution or other appropriate germicidal chemicals licensed by the Ministry of Health.
- Surface disinfectant with 0.5% of active chlorine or other disinfectant chemicals licensed by the Ministry of Health for cleaning surfaces with blood, fluid, vomit, excretion.
- Spray-on chemicals containing 0.1% of active chlorine or 0.05% of hydrogen peroxide (H2O2) for disinfection with automatic or non-automatic machine or sprayer.
- Special surface cleaning wipes and mop pads for screening and isolation areas, mops, buckets containing chemicals and buckets containing clean water, buckets collecting dirty mop pads.
5. Techniques for implementation
- Divide the area into two, with signs to avoid slipperiness, wetness before cleaning floors, halls and stairs.
- Wipe in a zigzag fashion, from top to bottom, inside and out, from the cleanest to the least clean area.
- When using chemical sprays, spray chemicals into cloth then wipe; If cleaning the floor, spray and wipe immediately. Do not spray when patient is present.
- Wipe cleaner areas first, then wipe more contaminated areas: First wipe surface of items that are not frequently touched, then wipe surface of frequently touched objects (When one object has been cleaned, replace the used cloth with a different cloth; or clean at most 20 m2 for one use of each mop pad, then use the other).
Air disinfection
- Air purifiers with HEPA/Plasma filter can be used and continuously work to disinfect the air in environments with people with confirmed or suspected SARS-CoV-2.
- If there is no air purifier, use ultraviolet lamp for an hour for each time of disinfection. Do it three times a day.
6. Method of implementation
- Step 1: Prepare adequate facilities of cleaning and disinfection (containers/buckets containing disinfectant solution, wipes, mops, etc.), use separate facilities for isolation areas (administrative area, isolation rooms, toilets, instrument and linen handling area, etc.).
- Step 2: The staff performing the environmental hygiene wears the personal protective equipment as instructed before entering the isolation area and during the process of cleaning and disinfecting the surface of the isolation area's environment (see Use of personal protective equipment).
- Step 3: Wet, wipe and collect waste in bags and containers of infectious waste in accordance with regulations before disinfecting wipe.
- Step 4: Disinfecting wipe shall comply with the following order:
+ Wipe with the detergent to clean disinfection, blood and fluids
+ Perform disinfecting wipe periodically with a disinfectant of specified concentration (with active chlorine concentration of 0.1%), let the surface dry for 10 minutes and
+ Wipe again with clean water to avoid chemical residues affecting patients. The frequency of cleaning on all surfaces in the isolation area is at least 02 times/day and when required. Apply the correct procedure of 2-bucket cleaning (one bucket of clean water, one bucket of disinfectant solution) and each wipe is with a clean cloth, do not wash again in buckets, each cloth is used no more than 20 m2 for a normal room and 10 m2 for an operating room.
+ Disinfection spray should only be used for areas that cannot be cleaned by wiping and when there is no patient, spray at the end of the day, after the patient is discharged from the hospital, after a surgery is completed, after a patient die, for chlorine with 0.1% (1,000g/l) of active chlorine concentration. Hydrogen peroxide can be used at a low concentration of 0.5% in high-risk areas for 60 minutes. After spraying, ensure ventilation (opening the door) is required after the completion of sterilization.
When wiping, pay attention to:
+ For surfaces that are frequently in contact (injection trolley, equipment and linen transporting vehicles, doorknobs, etc.), disinfect immediately after each use or contact.
+ For objects and surfaces with visible blood, secretions, feces, and vomitus, it is necessary to wipe with a disinfectant solution with 0.5% active chlorine concentration, let chemicals dry, the chemical exposure time to the environment is at least 10 minutes, then wipe with chemicals for the second time with a concentration of 0.1%, finally wipe with clean water.
- Step 5: Collect tools after cleaning the environment to clean and disinfect before removing them from the isolation area including waste that must be isolated (see Waste treatment, page 54), wiping cloth is put into isolation bags and transported to the laundry (See also Instruction on transportation of infected linen and waste out of the isolation area).
- Step 6: Healthcare workers take off personal protective equipment and do hand hygiene with soap and water, let hands dry, do hand hygiene with alcohol-based solution right after cleaning environment.
Attention:
- Healthcare workers' hands that have direct contact with patient’s blood, secretions and waste and after removing the personal protective equipment must be washed with soap and water.
- Before being removed from an isolation area, waste containing bags and containers, mop pads, surface cleaning wipes must be put into the second bags with the content: “Potential SARS-CoV-2 waste or linen” before being transported to handling area according to regulations.
5.1. Daily surface cleaning and disinfection for areas of treatment and care for patients.
The procedure is the same as above and requires strict adherence to regulations:
- Do the cleaning twice daily and when required. A table should be used to monitor disinfected surfaces every day.
- For each cleaning, it is necessary to clean visible organic substances (blood, biological fluids), inorganic substances with detergent and clean water before cleaning and disinfecting surfaces with disinfectant chemicals. Then, wipe with clean water. In the absence of blood and fluids, perform the step of disinfection wipe. If there is a large amount of blood, biological fluids, comply with procedures for blood and fluid treatment.
- Use SARS-CoV-2 disinfectant chemicals for all surfaces in the room and ensure the right time for contact with disinfectant chemicals. For example, at least 10 minutes with compounds with 0.1% of active chlorine.
Attention: Do not bring sanitary tools at an isolation area to another place and must separately collect and handle them.
5.2. Cleaning of patient reception and screening areas
- Patient reception and screening areas must be cleaned and have waste collected for at least 03 times per day (in cases of poor patient flow, shift work) and when needed (when they are heavily soiled, when there is blood and fluid, when a patient is in emergency conditions).
- After wiping these areas at the end of the day, it is recommended to spray disinfectants the entire patient reception and screening areas daily with chemicals containing 0.05% active chlorine or a solution of 0.5% hydrogen peroxide.
- If spraying disinfectants, spray only when there is no person, it is necessary to move patients to another place. Operate again after 30 minutes.
5.3. Cleaning after the patient is discharged/transferred/dead
- Move the other patient under isolation in the patient room (if any) to another isolation room before performing the final disinfection cleaning.
- Collect dirty tools and reusable linen into bags/containers to laundry and disinfection centers. Collect and remove the patient’s waste and other personal belongings in accordance with regulations on collection and management of infectious waste.
- Perform: (1). Clean organic substances (blood, biological fluids), inorganic substances with detergent and clean water if they are visibly scattered (2). Wipe the surfaces with chemical disinfectant, (3) Wipe again with clean water. In the absence of blood and fluids, perform the step of disinfection wipe. If there is a large amount of blood, biological fluids, comply with procedures for blood and fluid treatment.
- Use SARS-CoV-2 disinfectant chemicals for all surfaces in the room and ensure the right time for contact with disinfectant chemicals, for example at least 10 minutes with solutions containing 0.1% of active chlorine.
Details of chemical concentrations used in cleaning and disinfecting surfaces are in Appendix 11.
5.4. Disinfect surfaces spilled with blood or body fluids
- This should be done as soon as it appears or when blood or body fluids are detected.
- Wear adequate personal protective equipment.
- Remove blood stain or body fluids in the following order: (1) Use a wipe or gauze impregnated with solution containing 0.5% (5,000 ppm) of active chlorine to remove the blood (if there is a large amount of blood, it must be done many times until all blood on the surface is removed; (2) Put the blood-soaked wipe (gauze) into the container collecting infectious waste; (3) Use a wipe or gauze impregnated with a solution of 0.1% active chlorine to disinfect the surface of blood spilled area for the second time; (4) Wipe the disinfected surface with a cloth or gauze soaked in cleaning solution.
- Take off the personal protective equipment and do hand hygiene after going out of isolation rooms.
5.5. Cleaning mortuary and shrouding area of COVIS-19 patient
- Wear adequate protective equipment as prescribed for SARS-CoV-2.
- After the completion of shroud and autopsy, all instruments and surface of the surgical table, the operating room and facilities related to corpses must be cleaned to remove organic substances (blood, fluids, tissue) with detergents, then disinfected immediately with active chlorine solution of 0.5% and let them dry for 30 minutes to 1 hour and wipe again with clean water.
- Clean and disinfect sanitary facilities in accordance with the procedures.
- Take off the personal protective equipment and do hand hygiene after finishing work.
5.6. Cleaning toilets in screening, isolation, reception and treatment areas
- Toilets must be arranged separately for men, women and children.
- People with infected or suspected SARS-COV-2 must use a separate toilet separated from the patient room, the toilet bowls’ surfaces and lids must be cleaned and disinfected with a disinfectant solution containing 0.1% of active chlorine at least 04 times/day and when required; When flushing, the toilet lid must be closed to prevent dirty droplets.
- In case there is no toilets built separately, to install mobile toilets where containers of toilets’ waste must contain chemicals with 1.0% active chlorine and when the containers are full, waste must be safely handled before being putted into general liquid waste systems or handled.
- In case patients cannot use the toilet, immediately pour his stools, urine, secretions contained in potty, bucket, pot, speculum into the toilet bowl. Immediately clean and disinfect the potty, bucket, pot, speculum and surfaces of toilet bowls, urinal bowls with a disinfectant solution containing 0.5% active chlorine.
- Make sure the availability of soap and clean water, toilet paper, and regular detergent in toilet.
- Sanitary staff wear personal protective equipment as prescribed, elbow-length rubber gloves, a waterproof apron if a lot of water splashes around, waterproof boots or thick shoe covers when cleaning. Take off them at anteroom before going outside.
Attention:
- The toilet is always last to clean and disinfect, it is strictly forbidden to do the opposite. If there arises the outside to clean after cleaning the toilet, to replace with a new set of personal protective equipment and new cleaning equipment for cleaning it.
- The toilet building materials must be easy to clean and disinfect.
- Ensure good ventilation, avoid spreading gas of toilet to an area with many passersby.
5.7. Cleaning of sanitary tools
- Hospital sanitary tools must be cleaned after every shift and at the end of each day.
- Sanitary tools to be treated, including mop handle, bucket/basin containing chemical, rinse water/soaking water for disinfection must be cleaned with clean water and soap and placed at drying place as regulated.
- Disinfect buckets/basins containing cleaning and disinfecting solution at the active chlorine concentration of 0.1%, rinse again with clean water and place them on the drying rack.
- Clean up sanitary tools and place them properly. Do not use untreated cleaning tools for daily cleaning.
6. Inspection and surveillance
- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with the procedure for daily or unexpected environmental disinfection.
- Daily monitoring of compliance of healthcare workers in the implementation of the procedure for disinfection and cleaning of surfaces, spills of blood, biological fluids, use of personal protective equipment, cleaning when working in isolation and treatment areas of people with confirmed or suspected SARS-CoV-2.
- Surveillance results should be immediately given to the supervised person and reported to the department head and the hospital leader.
See also Instruction on cleaning of environmental surfaces in medical examination and treatment establishments in the Decision No. 3916/QD-BYT dated 28/08/2017 of the Minister of Health.
CLEANING AND DISINFECTION OF TRANSPORTATION VEHICLES FOR PEOPLE WITH CONFIRMED OR SUSPECTED SARS-COV-2
The medical examination and treatment establishments must strictly apply technical procedures and principles of environmental control, surface hygiene control and safety practices control in the use of personal protective equipment while transporting people with confirmed or suspected SARS-CoV-2 within and outside the hospitals.
1. Objectives
- Healthcare workers properly and strictly follow regulations on cleaning and disinfection of surfaces of transportation vehicles for peoples with confirmed or suspected SARS-CoV-2.
- Prevent SARS-CoV-2 infection due to contact with surfaces of transportation vehicles for people with confirmed or suspected SARS-CoV-2.
- Ensure the safety for healthcare workers in charge of transportation and community.
2. Principles of implementation
- The surfaces of transportation vehicles, utensils requiring the cleaning and disinfection include: the inner compartment of patient transportation vehicles (stretchers, control panels of medical equipment, adjacent floors, walls, ceilings and working surfaces, door handles, keyboards and phones, etc.) and the outer surface of transportation vehicles (door handles, doors, the entire outer surface of vehicles).
- Persons in charge of handling transportation vehicles (are the persons who are directly involved in transporting or who are assigned to perform the final cleaning of transportation vehicles) must be trained and properly adhere to principles and techniques of cleaning the surface of machines, equipment and transportation vehicles, measures of standard precautions and contact transmission precautions.
- The hospital has regulations on fully equipped area for handling of transportation vehicles and fully equip personal protective equipment, chemicals and tools to ensure the safe handling of vehicles.
- All patient transportation vehicles, devices for patient intervention and care at the end of use must be handled immediately according to the procedure before using for next patients.
3. Subjects and scopes of application
- All vehicles used for patient transportation to the hospital, for transfer of hospital and within the hospital.
- All healthcare workers participating in transporting people with confirmed or suspected SARS-CoV-2 at all rooms and departments.
4. Vehicles
- Personal protective equipment: have enough PPEs, N95 respirators, medical masks, goggles or face shields, rubber boots, clean gloves, sterile gloves for separate invasive procedures to be replaced and used as needed.
- Cleaning chemicals and disinfectants:
+ Alcohol-based hand sanitizer.
+ Surface disinfectant with 0.1% and 0.5% active chlorine ingredients, ethanol 70% or other disinfectants in the list licensed by the Ministry of Health.
- Equipment for handling: Sprayers, wipes, waste containing bags.
- Arrange separate area for handling of transportation vehicles within the hospital, preferably near the entrance, if necessary, handle them at pick-up and drop-off points for patients.
5. Procedure
To comply with the following procedure:
- Step 1: Dilute chemicals as regulated and place it in chemical containers at the treatment area.
- Step 2: Wear person protective equipment according to guidance.
- Step 3: Collect tools and waste into yellow bags/containers then seal it tightly, clearly indicate the waste generated from or to the centralized waste treatment area.
- Step 4: Clean all surfaces of transportation vehicles with disinfectants, leave it for at least 10 minutes then clean again with cleaning chemicals (detergents or clean water with soap), then dry or blow dry. In case of excessive blood/fluid or spillage of blood or body fluid (eg: vomitus, blood, biological secretions...), at first use a disposable tissue impregnated with 0.5% active chlorine to localize and remove, cover the spill by a cloth soaked with 0.5% active chlorine solution for at least 10 minutes, then wipe off by disinfectant solution with 0.1% active chlorine.
- Step 5: Once the cleaning is done, personal protective equipment is discarded in a yellow bag or container with the lid, and moved to the disinfection or destruction area, then perform hand hygiene with disinfectant soap and personal hygiene.
Attention: For vehicles transporting people with confirmed or suspected SARS-CoV-2, spray disinfectant with disinfectant solution with concentration of 0.1% active chlorine:
- When patients go away, spray the outside surface of the vehicle, including the body, tire and underbody.
- When patients arrive, spray the outside and inside surfaces of the vehicle after patients leave it.
6. Inspection, monitoring and responsibility
- Infection Control Department, Nursing Department, Head of Departments and Head Nurses of relevant departments are responsible for training, inspecting, monitoring and urging the strict implementation of cleaning procedures for transportation vehicles for patients with confirmed or suspected SARS-CoV-2.
- General Planning Department shall perform the checking of emergency equipment, ambulances and emergency regulations for prevention of epidemics and natural disasters.
- Medical Supplies and Equipment Department, Pharmacy Department (or unit assigned with the duty of supplies provision) is responsible for providing adequate personal protective equipment and chemicals for sterilization and disinfection in the list licensed by the Ministry of Health.
- Infection Control Department will monitor the compliance with equipment cleaning and disinfection procedure, medical waste treatment and environmental sanitation for areas where cleaning and disinfection of equipment are performed.
COLLECTION, PRESERVATION, PACKAGING AND TRANSPORT OF SPECIMEN
All biological specimens from people with confirmed or suspected SARS-CoV-2 are potential and dangerous sources of infection for persons who sample, collect, transport, preserve and handle them. Strict compliance with requirements of level 2 biosafety is required when contacting and handling this source of specimen.
1. Objectives
- Prevention of SARS-CoV-2 infection through contact with specimens and people having contact with patients during the process of collecting, preserving, packaging and transporting, handling and performing specimen-related tests related to people with confirmed or suspected SARS-CoV-2.
- All trained sampling personnel must correctly and strictly follow the procedures and regulations when collecting, preserving, and transporting specimens of people with confirmed or suspected SARS-CoV-2.
- Avoid spreading disease sources and ensure safety for healthcare workers and the environment.
2. Principles of implementation
Prevention of contact-borne infection is a top priority in the procedure for sampling, preserving, packaging, transporting, handling specimen and doing tests related to specimens of people with confirmed or suspected SARS-CoV-2.
2.1. Requirements on persons sampling, preserving, packaging, transporting specimens of people with confirmed or suspected SARS-CoV-2
Persons who sample, store, pack, transport, handle and do tests related to patient specimens of people with confirmed or suspected SARS-CoV-2 must be the healthcare workers who are trained with good practice skills of directions on infection prevention.
- Strictly comply with biosafety regulations in collecting, preserving, packaging, transporting, handling and doing tests related to specimens, transmission of agents via the air, droplets, and the route of contact, blood (when taking blood specimens for testing).
- Use personal protective equipment skillfully and properly.
- Understand the risk of infection, have the ability to detect and assess risks for individuals, have knowledge of health control after performing tasks and handle themselves in accordance with the exposure procedure.
- It is ideal that healthcare workers who are monitoring and caring for suspected patients take specimens, minimizing the number of people having contact with patients.
2.2. Requirements for instruments
All instruments used to collect, store, package and transport specimens and all the testing instruments, redundant specimen of the people with confirmed or suspected SARS-CoV-2 are waste with high risk of infection and must be disinfected at the Laboratory before becoming infectious medical waste.
- Priority is given to use the disposable tools that are destroyed immediately after use as infectious waste.
- Instruments if reused, must be disinfected and sterilized in accordance with regulations, there must be separate treatment tanks according to regulations on disinfection and sterilization.
- Instruments separately used for each patient must be collected and separately handled.
2.3. Requirements for sampling and testing areas
- A sampling area must be the isolation area according to regulations.
- A testing area must comply with regulations on biosafety level in conformity with testing techniques.
3. Subjects and measures of application
- Healthcare workers must strictly follow regulations on biosafety and proficiently use the personal protective equipment.
- People with confirmed or suspected SARS-CoV-2 must be kept in the isolation areas.
- Sampling instruments and testing instruments and redundant specimens of people with confirmed or suspected SARS-CoV-2 must be treated as medical waste with high risk of infection.
4. Vehicles
4.1. Personal protective equipment
- Anti-epidemic disposable clothes.
- Waterproof cape.
- Hood or cape covering head and neck with waterproof material.
- Mask with high filtration capacity (for example, N95), or mask with filter and breathing support component (boosting oxygen).
- Goggles or face shield.
- Double-layer gloves, first layer (inner layer) as medical gloves always kept clean, avoid contact with dirty equipment.
- Rubber boots/waterproof boots with high neck.
- Hand sanitizer containing alcohol/soap for hand hygiene.
4.2. Specimen taking instruments
- Sterile soft and hard handle cotton swabs (Sampling rod: the end of the rod is made of synthetic fiber, should not use swabs with a wooden or calcium handle.
- Tongue depressors.
- The collected specimens are contained in a 3 ml medium tube (VTM, UTM or physiological saline 0.9%).
4.2.1. Respiratory specimens: At least 01 respiratory specimen:
Upper respiratory tract specimens: Nasopharyngeal fluid specimens.
- Nasopharyngeal fluid: Sterile soft handle cotton swabs (as regulated by Laboratory).
If nasopharyngeal fluid specimens cannot be obtained, one of the following samples may be collected:
+ Upper respiratory tract specimens:
•Throat fluid swab specimens: Sterile hard handle cotton swabs to collect specimens (as regulated by Laboratory).
• Nasal fluid swab specimens (both), for people with symptoms. Nasal/nasopharyngeal rinsing fluid;
• Mouthwash fluid: physiological saline, sterile plastic cup (specimens are collected into petri dishes or beaker and diluted in the specimen medium as regulated by Laboratory).
+ Lower respiratory tract specimens
• Sputum
• Alveolar fluid, endotracheal fluid, pleural fluid (specialized instruments with the help of a clinician). Organization of lungs, bronchi, alveoli
4.2.2. Blood specimen: specimen for serology testing
- Sterile 10ml syringe
- Blood collection tube with or without anticoagulant (as regulated by Laboratory)
- Tourniquet, cotton balls, alcohol, etc.
Requirements for blood specimens:
+ Blood specimen of acute phase.
+ Blood samples of recovery phase (after 14 days -21 days after onset of illness).
+ Volume of blood sampling: 03ml - 05ml.
Ø Attention: Blood sampling is not required, depending on the serology testing, localities, units and establishments shall develop specific plans.
4.2.3. Specimen packaging
- Plastic boxes, containers for specimen transportation with safety lids, safety racks for specimen storage or plastic bags for packaging of specimens.
- Styrofoam cooler and container for specimen transportation according to regulations.
- Antiseptic gauze (for handling of spillage or splashing of specimens)
4.3. Information on specimen tube
- Name of patient (or specimen code).
- Age.
- Date and time of specimen collection.
- Type of specimen.
- Other necessary information as required by Laboratory.
4.4. Test request form and epidemiological investigation questionnaire
To fully fill in information according to form as specified.
5. Step of implementation
5.1. Wear person protective equipment
Properly wearing of personal protective equipment (see also the Use of personal protective equipment). Pay attention to wearing mask N95 or N96 and 2-layer gloves when taking specimens.
5.2. Regulations on taking specimens
5.2.1. Specimens
It is obligatory to take 01 respiratory specimen; an additional blood specimen can be taken upon request; the specimens are as follows:
- Upper respiratory tract specimens (in order of priority):
+ Nasopharyngeal fluid (Nasopharyngeal fluid swab).
+ Throat fluid swab
+ Nasal fluid swab specimens (both).
+ Nasal/nasopharyngeal rinsing fluid.
+ Throat rinsing fluid.
- Lower respiratory tract specimens:
+ Sputum (when requested)
+ Alveolar fluid, endotracheal fluid, pleural fluid, etc.
+ Organization of lungs, bronchi, alveoli (when indicated).
- Blood specimen: 3-5 ml of venous blood with or without EDTA anticoagulant. Serum or plasma specimens are stored as required by the Laboratory (perform the test as required).
5.2.2. Time to collect specimens
The time of collection of respiratory specimens should be taken as soon as possible after the onset.
Table 4. Time of collection of specimens for SARS-CoV-2 confirmation
Type of specimen | Appropriate time of specimen collection |
Upper respiratory tract specimens (Nasopharyngeal fluid swab, throat fluid swab, nasal fluid swab specimens (both), nasal/nasopharyngeal rinsing fluid, throat rinsing fluid) | On day 0 to day 7 after onset of disease |
Lower respiratory tract specimens (alveolar fluid, endothelial fluid, pleural fluid, etc.) | On day 0 to day 14 after onset of disease |
Blood specimen of acute phase | At the same time of the upper respiratory specimen (on day 0 to day 7 after the onset of disease) |
Blood samples of recovery phase | On day 14, 28 or 3 months after the onset of disease) |
Alveolar organization | When indicated |
5.2.3. Specimen taking techniques
a. Nasopharyngeal fluid (Nasopharyngeal fluid specimens)
- Ask patient to sit still, face slightly back, children must be kept by an adult.
- The person taking specimen tilts the patient's head back about 70°, hands holding patient’s neck.
- Use the other hand to gently insert the cotton swab into one nostril, pushing and turning to make the cotton swab easier to go forward about ½ length from the nose edge to the earlobe of the same side.
Attention: if you have not reached such a depth but feel a clear resistance, remove the cotton swab and try to get specimen from the other nostril. When you feel the cotton swab touch the back of the nose and throat, stop, turn and slowly withdraw the cotton swab.
- Hold the cotton swab at the sampling site for 5 seconds to ensure maximum infiltration.
- Slowly turn and withdraw the cotton swab.
- Place the tip of a cotton swab in the medium canister and break the swab handle at the marking point to have a length consistent with the length of the medium canister.
- Recap, tighten and wrap with paraffin paper (if any). Store the specimen at a temperature of 2-8°C before transportation to the laboratory. If the specimens are not transported to the laboratory within 48 hours after being taken, the specimens must be stored at minus 70°C (-70 °C). | 
|
Attention: For small children, let them sit on the parent's lap, the child's back is facing parent's chest. Parent need to hold the baby's body and arms tightly. Ask the parent to tilt the baby's head back. | Figure 20: Take nasopharyngeal fluid |
b. Throat fluid swab (Throat fluid swab specimens)
- Ask the patient to open his mouth wide.
- Use the instrument to gently press the patient tongue.
- Insert the cotton swab into the oropharynx, rub and gently rotate 3-4 times at the 2 sides of the tonsils and the back wall of the throat to get fluids and cells.
Figure 21: Take throat fluid swab
- After taking the specimen, the cotton swab is put into a tube containing 3 ml of medium for storage. Note, the cotton swab tip must be completely submerged in the medium, and if the cotton swab is longer than the medium canister, it is necessary to break/cut the swab handle to fit the length of the medium canister.
c. Nasal fluid swab specimens
- Tilt the patient's head back about 70°
- Insert the swab about 02 cm into a patient's nose, rotate the swab against the nasal wall for about 03 seconds. Rotate several times at the nose wall
- After taking specimens in one side of the nose, use the same swab for the other nose.
- Place the swab in the tube containing the transport media, break the swab handle to fit the length of the transport media tube, close the lid, tighten.
Figure 22: Take nasal fluid
d. Nasal/nasopharyngeal rinsing fluid
- Attach the sterile catheter to the suction device.
- Tilt the patient's head back about 70°with a few drops of sterile saline solution into each nostril.
Insert the catheter into the nose (the tube should be deep in the distance from a nose wing to earlobe), start to gently suck, slowly take it out while rotating gently.
- Place specimens in the tube containing the transport medium
Figure 23: Take nasal/nasopharyngeal rinsing fluid
e. Mouthwash fluid
Patients gargle with 10 ml of washing solution (physiological saline). Throat rinsing fluid is collected into a beaker or petri dish and diluted at 1:2 in a viral storage medium.
g. Endotracheal fluid
The patient is under mechanical ventilation and intubated. Use a suction tube, placed in the endotracheal route and use the syringe to suck the endotracheal fluid out along the intubation tube, put the endotracheal fluid into the viral storage medium tube.
h. Take blood specimen (if requested)
Use a sterile needle and syringe to take 3ml-5ml of venous blood and transfer it into a tube (with or without EDTA anticoagulant) and store it at 2°C-8°C for 24 hours.
Attention:
- Write the patient’s name, age and address, type of specimen, day of sampling on the specimen holding tube.
- Specimens collected in the lower respiratory tract (endotracheal, alveolar, pleural fluid) must be coordinated with clinicians during the collection of patient specimens.
5.2.4. Disinfection of instruments and specimen collection area
- Sampling instruments and personal protective equipment must be treated as infectious waste, the entire protective equipment: put them into a dedicated plastic bag for medical waste that can withstand high temperatures, together with dirty tools (use new gloves and masks), etc. Fasten and do wet drying at 120°C for 30 minutes before disposing of them together with other medical waste or possibly incinerate them in the hospital’ waste incinerator.
- Surfaces of specimen collection area must be disinfected as isolation room.
- Wash hands with soap and disinfect all tools and sampling areas with 0.1% chloramine; cold Thermos bottle for transporting specimens to the laboratory.
5.3. Regulations on specimen storage
Specimens after being collected should be transported to the Laboratory in the shortest possible time:
- Specimens are stored at 2°C-8°C, and transported to the Laboratory as soon as possible, ensure no more than 48 hours after collection.
- The specimens are stored at -70°C in the event that the expected time of transportation to the laboratory is later than 48 hours after collection. If the specimen is being stored at -70°C, it must also be frozen when being transported to the laboratory, avoiding repeated thawing that reduces the quality of the specimen.
- Do not store specimens in the freeze compartment of fridge or -20°C.
5.4. Regulations on specimen packaging
- Comply with the instructions, time, and temperature as prescribed.
- Avoid specimen damage, loss of specimens, and avoid specimen contamination.
- Avoid contamination between samples, avoid human contact with samples and avoid causing environmental contamination.
- The papers related to specimen (testing request form, specimen information, list of specimens, etc.) must be put in a separate plastic bag and avoid contact with the specimen. Specimens when being transported must be packaged by the 3-layer principle to ensure biosecurity according to the Circular No. 40/2018/TT-BYT on management of specimens.
Figure 24: Biosecurity with package according to the 3-layer principle
5.4.1. Packaging specimen for transportation to perform routine tests (immunological testing when required, biochemistry, and hematology)
- The innermost layer: the specimen vial as required by Laboratory. Do not allow the specimens to spill out.
Figure 25: Packaging specimen (03 layers) for transportation in hospital to perform routine tests
- Middle layer: plastic rack, styrofoam rack, plastic box to keep the specimen upright.
- Outer layer: rigid plastic box with lid and handle, labeled biohazard on the box.
5.4.2. Packaging specimen for long-distance transportation to do tests for SARS-CoV-2 confirmation
Transported specimens must be carefully packed in 03 protective layers as guided by the World Health Organization.
- The tube contains the transport medium: Directly contains specimens. Plastic tube with tight lid properly closed.
- Plastic box, or rack: Contains specimen tube.
Respiratory specimens and blood samples of the same patient are placed in a sealed plastic box with screw cap tightly closed or plastic rack for specimen tube.
- Container for specimen transportation: Contains box (or rack) of specimen.
+ Reliable container with tight lid to ensure no break.
+ Temperature retention (use of cooler).
- Steps of specimen packaging and transportation.
Figure 26: Specimen packaging and transportation
Attention:
- Attach the test request form.
- Outside the specimen transportation container, there are logos as defined by WHO (biohazard label, directional label and impact avoidance label) painted on it.
Figure 27: Sample of biohazard label, directional label and impact avoidance label
(Issued together with the Government’s Decree No. 92/2010/ND-CP dated August 30, 2010)
5.5. Regulations on specimen transportation
- Notify the Laboratory of the day of sending and expected time of arrival to Laboratory.
- Specimens are transported to the Laboratory by road or air as soon as possible.
- Within the hospital, transporting specimens by hand. Do not use pneumatic specimen transport system.
- Absolutely avoid spillage and breakage of specimen tube during transportation.
- Ensure that all staff transporting specimen are trained in safe handling practices and procedures for decontamination of blood and fluid spillage.
- Avoid spillage and breakage of specimen tube during transportation.
- If the specimen is being stored at 2-8°C, it must also be stored at 2-8°C when being transported to the laboratory.
- If the specimen is being stored at -70°C, it must also be frozen when being transported to the laboratory, avoiding repeated thawing that reduces the quality of the specimen.
- Specimens should be transported together with the test request Form with all prescribed information.
6. Inspection and surveillance
- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with procedures, regulations on biosafety, skillful use of personal protective equipment during collection, storage, packaging, transportation, handling and performance of tests related to COVID-19 specimens.
- Monitor the treatment of medical waste with high risk of infection for specimen collecting instruments, testing instruments and residue of specimen after testing.
- Monitor the treatment of areas of specimen collection, handling and performance of tests related to COVID-19.
(See more in Guidance on diagnosis and treatment of acute pneumonia caused by a new strain of Coronavirus (nCoV) in the Decision No. 3351/QD-BYT dated July 29, 2020 of the Ministry of Health that guide diagnosis and treatment of COVID-19 caused by a new strain of Coronavirus (SARS-Cov-2), replacing the “Guidance on diagnosis and treatment of acute respiratory infections caused by SARS-CoV-2”).
PREVENTION OF SARS-COV-2 TRASMISSION AT MICROBIOLOGY, TESTING DEPARTMENTS
1. Objectives
- Prevent the SARS-CoV-2 infection through the air, by droplets and contact from types of specimen and persons contacting patients during performance of specimen testing of persons with confirmed or suspected of SARS-CoV-2.
- All staff in laboratory must strictly and properly follow the procedures and regulations upon collection, storage and transport of specimen.
- Avoid spreading disease sources and ensure safety for healthcare workers and the environment.
2. Subjects of application
- Laboratory staff must strictly follow regulations on biological safety and must proficiently use personal protective equipment.
- All specimens of persons with confirmed or suspected SARS-CoV-2 may come from outpatient department, A&E, department of infectious diseases, etc or transported from other medical examination and treatment establishments.
3. Method of application
3.1. Specimen
- Upper respiratory tract specimens.
- Lower respiratory tract specimens.
- Blood and serum specimen
3.2. Testing of suspected cases
- Hematological testing.
- Biochemical testing.
- Biological testing, differential diagnosis:
+ Severe flu.
+ Atypical pneumonia.
+ Septicemia causing renal and respiratory failure.
+ Acute hand-foot-and-mouth disease with complications of respiratory and renal failure.
- Other routine tests.
3.3. Test for SARS-CoV-2 determination
- Rapid test to find antibodies in the patients’ blood
- Detecting SARS-CoV-2 with the Real time RT-PCR or Next Generation Sequencing – NGS technique.
4. Requirements for biosafety assurance
Preventing the SARS-CoV-2 infection by droplets, contact and aerosol dispersion when performing aerosol manipulation is the first priority during testing for people with confirmed or suspected SARS-CoV-2.
4.1. Material facilities
- Routine tests: Biosafety level II
- The tests for SARS-CoV-2 diagnosis: Biosafety level II
4.2. Equipment
- Ensure the requirements on equipment for Biosafety level II Laboratories.
- Biosafety cabinet level II calibrated and certified.
- Personal protective equipment:
+ Routine tests: general personal protective equipment (Clothes, hat, glasses, mask, face shield).
+ Tests for definitive diagnosis of SARS-CoV-2: Wear adequate personal protective equipment, including: epidemic resistant costumes of level 3 or higher, powderless gloves, N95 mask, goggles or face shield.
4.3. Laboratory staff
- The Laboratory staff must be trained in biosafety, experienced and proficient when performing tests for people with confirmed or suspected SARS-CoV-2. The specialized staff should be assigned to do such tests.
- Strictly follow the regulations on biosafety and use personal protective equipment properly and proficiently.
- When doing routine tests: wear the general personal protective equipment such as gloves, waterproof gown, face shields, goggles, masks.
- When performing tests for definitive diagnosis of SARS-CoV-2, wear all personal protective equipment, including TWO pairs of gloves, epidemic resistant costumes, N95 mask, face shield or goggles.
- While wearing gloves for testing related to specimen of people confirmed or suspected of SARS-CoV-2 infection, do not touch the keyboard controlling machinery, doorknobs, phones, electrical switches, etc.
- Staff performing tests of people confirmed or suspected of SARS-CoV-2 must not wear personal protective equipment when going out of SARS-CoV-2 Laboratory.
- Understand risks of infection, be able to detect and assess risks for individuals, have knowledge of health control after carrying out duties and handle themselves in accordance with the procedures in case of exposure.
- Absolutely do not contact bare hands with specimens and testing tools for persons confirmed or suspected of SARS-CoV-2.
- When performing tests related to specimens of patients with positive result of SARS-CoV-2 or suspected patients, do not touch face, nose, mouth.
- Laboratory surfaces exposed specimens must be properly disinfected according to procedures for cleaning of SARS-CoV-2 surfaces
Specimen and waste related to specimen of Laboratory department must be put into heat resistant stainless steel container and steamed for sterilization before being transported to the collection place. In the absence of an autoclave, it must be put into the waste container, packed in 02 bags and transported to the collection place for treatment as potential SARS-CoV-2 waste.
5. Inspection and surveillance
The Department of infection control, Nursing Department, Heads of Departments and Head Nurses of the relevant departments are responsible for training, inspection, surveillance and urging of the strict compliance with procedures and regulations on biosafety when performing tests for patients confirmed or suspected of SARS-CoV-2.
- Supervise healthcare workers’ strict adherence to disinfection of specimen collection tools and areas.
- Supervise healthcare workers’ strict adherence to regulations on biosafety and proficient use of personal protective equipment during the process of testing.
- Supervise the treatment of reused instruments after doing tests.
- Supervise the treatment of medical waste with high risk of infection for specimens after doing tests.
- Supervise the treatment of laboratory environment as an isolated area.
Attention:
- Specimen collection area must be treated as an isolated area.
- In laboratory, ensure ventilation must be ensured and must not exhaust gas to places where many people pass by or to corridor or other rooms.
Testing operations with risk of nebulization, droplets should be carried out in a biosafety cabinet of level II, such as opening test tubes containing specimens; division and dilution of specimens; mixture of specimens (with vortex mixer); DNA/RNA extraction.
- Gloved hands for testing related to specimens of COVID-19 confirmed patients must not touch the keyboard controlling machinery, doorknobs, phones, electrical switches, etc.
- When taking off personal protective costumes (gloves, gown, mask, etc.), roll the dirty side (the outer side) inward to limit the risk of spreading the infectious agent to collection tools and means of transport.
- Sampling instruments and specimens of people with confirmed or suspected SARS-CoV-2 must be treated as medical waste with high risk of infection.
PREVENTION AND CONTROL OF SARS-COV-2 INFECTION FOR HEMODIALYSIS PATIENTS
1. Objective
- Healthcare workers and patients must comply with regulations on COVID-19 prevention and control for hemodialysis patients.
- Prevention and control of SARS-CoV-2 infection for healthcare workers and patients in hemodialysis units.
2. Scope of application
- Units having hemodialysis patients.
- Healthcare workers and patients in hemodialysis units.
3. General principles
- Healthcare workers and patients in hemodialysis units must be trained on measures to prevent and control SARS-CoV-2.
- Early detect and promptly apply quarantine measure for hemodialysis patients who are confirmed or suspected to be infected with SARS-CoV-2.
- Arrange a separate hemodialysis area for hemodialysis patients who are confirmed or suspected to be infected with SARS-CoV-2. In case of failing to arrange a separate area, it is required to arrange a separate dialysis case for this group of patients at the end of the day.
- Assign healthcare workers/private care groups to treat hemodialysis patients for a group of patients who are confirmed or suspected to be infected with SARS-CoV-2, and adhere to standard precautions and infection-based prevention in providing care,
- During the dialysis session, the patient should wear a medical mask while in the waiting room. In waiting rooms, a minimum distance of 1-2 m should be maintained between patients. In case where the waiting room is too tight, develop a scheduled group dialysis plan to reduce the density of patients waiting at the dialysis site.
Patients and their families are encouraged to transport by private vehicles. In the case of transporting patients by medical facility vehicles, the number of patients transported on the same trip should be minimized. Drivers and patients shall wear medical masks and disinfect vehicles immediately after each trip and every day.
4. Means
- Hand hygiene means: Hand wash soap and alcohol-based hand hygiene solutions.
- Personal protective equipment: are those disposable things (gloves, paper hats, medical masks, gowns, goggles, aprons). All of them must be waterproof.
- Utensils for waste collection: yellow bag and bin with size big enough to collect after-use personal protective equipment.
- Utensils for environmental hygiene and disinfection: Towel used to clean surface, hand sprayer or hand spraying machine.
5. Execution
5.1. Training for healthcare workers and hemodialysis patients
- Moments and procedures for hand hygiene
- Principles of respiratory hygiene
- Designation, engineering and removal of personal protective equipment.
5.2. Screening, early detecting and applying quarantine measure for SARS-CoV-2 confirmed or suspected patients
- Via mass media; patients are encouraged to check temperature by themselves at home and actively notify screening staff when getting a fever or showing respiratory tract infection symptoms such as: runny nose, sore throat, cough, shortness of breath, or had been in close contact with SARS-CoV-2 confirmed or suspected patients.
- Have masks, disposable hand towels/tissues, and surface wipes ready in the patient screening area to provide them when needed.
- Arrange screening staff at the entrance/exit to check the patient's temperature, guide the patient to make medical declaration according to regulations for each time of dialysis.
- For areas where equipped with body temperature scanners, glass/plastic barriers that separate from the patient, the screening staff that be able to maintain a distance of at least 02 meters from the patient, just have to wear a mask without other personal protective equipment.
- If the screening staff have to be in contact with patients with a distance of less than 02 meters, he/she is required to put on personal protective equipment, including medical masks, gowns, goggles and gloves.
- If the patient notifies that he/she shows suspected expression: Guide him/her to wear masks and discard the mask; arranging the patient to wait at a temporary quarantine area at that department, with a distance of at least 02 meters away from other patients and healthcare workers when waiting to be transferred to the screening area.
5.3. Artificial kidney chamber hygiene
- Clean contact surfaces regularly 2 - 3 times/with a solution containing 0.1% active chlorine, or Ethanol alcohol or isopropanol with concentration of 60% - 80% for small surfaces.
- Wash bed sheets and other linens after every dialysis case.
- Only keep essential things and equipment in the chamber.
- Hand washing sink must be fully equipped with soap and disposable tissues.
- Do not leave fresh flowers and ornamental plants in the patient room.
5.4. Protection of hemodialysis patients
- Instruct patients to limit close contact with others, especially in high-risk areas that have been warned: mass gathering, tight and badly-ventilated areas, etc.
- Minimize people to go in and out of the artificial kidney chamber and minimize the density of people in the active dialysis area.
- Healthcare workers, serving staff and patient visitors shall put on disposable protective outfit, including: Gloves, masks, gowns, shoes covers, caps and medical masks.
- Only healthy people are allowed to provide care/treatment or visit hemodialysis patients.
- Wash hand properly before and after having meals or using the toilet.
- Patients shall have a shower every day.
- Cover nose/mouth by disposable tissues when coughing or sneezing.
- Maintain the diet for people suffering from immunodeficiency diseases: drink bottled water or specially pasteurized water, bowls, chopsticks and other eating utensils sanitized with clean water and chemicals, cleansed and dried after washing, if possible use disposable eating utensils.
6. Examination, supervision and duties
- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses shall be responsible for training, inspection, surveillance and urging of strict compliance with these regulations.
- Units having hemodialysis patients: shall comply with regulations in their managed areas, ensure that patients and their families comply with regulations on distancing, and minimize people entering into, and exit from such areas.
- The General Planning Department: shall monitor the examination, reception and report to ask for the Hospital Management to resolve problems arising during the execution of this regulation.
- Patients and their families: shall comply with the regulations on hand hygiene, use of personal protective equipment, keeping disease prevention order and hygiene and distance of the unit where they are under treatment.
PREVENTION AND CONTROL OF INFECTION WHEN PERFORMING MEDICAL PROCEDURES OR OPERATING ON SARS-COV-2 CONFIRMED OR SUSPECTED PATIENTS
1. Objectives and requirements
1.1. Objectives
- Ensure the safety for patients, healthcare workers and communities.
- Prevent SARS-CoV-2 from spreading and transmitting during the surgery or medical procedures.
1.2. Requirements
All healthcare workers in the surgical team must:
- Identify risk factors for SARS-CoV-2 infection when performing surgery or procedures for SARS-CoV-2 confirmed or suspected persons.
- Comply with process of surgery or procedures for SARS-CoV-2 confirmed or suspected persons.
2. Subjects and scopes of application
2.1. Subjects
- Healthcare workers participating in the preparation for surgery or procedures and post-surgery.
- Relevant staff, supervision and support departments (workers who clean and disinfect tools and linens, etc.).
2.2. Scope
- The Emergency Departments and Clinical Departments having surgery patients who are suspected or confirmed to be infected with SARS-CoV-2; emergency chambers of field hospitals; isolation areas of medical examination and treatment establishments.
- Departments of Surgery, Anesthesia and Intensive Care/Surgery suites of field hospitals.
- Relevant support departments: General Planning Department; equipment; nurses; departments in charge of hygiene, waste collection and surgical instrument handling.
3. Principles
- Apply only to emergency or delayed surgery when someone suspected or confirmed to be infected with SARS-CoV-2.
- Medical facilities must promulgate regulations, processes and guidance on performing surgery for SARS-CoV-2 confirmed or suspected persons.
- Provide training courses on promulgated regulations and processes for healthcare workers who participate in the surgery in order to ensure safety for healthcare workers, patients and environment.
- Provide adequate essential means for performing surgery/procedures for SARS-CoV-2 confirmed or suspected persons.
+ A operating theatre should be a negative pressure operating theatre. In case where a negative pressure operating theatre is not available, the system of positive pressure operating theatres or operating theatre with local air conditioning, that is set at negative pressure, may be used.
+ It is necessary to stream the movement of the patient, the surgical team, and the best to transport dirty items after surgery to limit the spread of pathogens. In the process of transporting the patient to the surgical and procedure room, the patient should wear a medical mask; if he/she has respiratory distress and requires manual ventilation, it is necessary to install the HEPA Filter on the connection between the bag and the endotracheal tube.
+ Costumes for surgeons and surgical team: Wearing the personal protective equipment followed by surgical suits (or sterilized Tyvec suits), N95 mask (or FFP level 2 or 3) and eye protection goggles are required.
+ Handling of medical instruments: Disposable medical instruments are given priority and such instruments shall be handled in accordance with this Decision.
+ Operating theatre hygiene.
+ Waste management.
+ Make a list of officers participating in the technical team for periodical supervision for 14 days.
+ Bilevel positive airway pressure (BiPAP) or continuous Positive Airway Pressure (CPAP) machine should not be used for procedures involving anesthesia or aerosol generating respiratory support.
+ Use of wires of ventilator, dialysis or kidney machine, pacemaker, disposable and non-reusable devices are given priority. Use cuff endotracheal tube (Hi-Lo EVAC), avoid using fiber optic cable unless specifically indicated.
4. Steps of implementation
4.1. Preparation for patients
- At the reception of SARS-CoV-2 confirmed or suspected persons who are indicated for emergency surgery.
- At the clinical department (in case of uncareful screening or the patient is at the isolation area).
- Do not move the patient, complete dossiers and necessary assays for emergency consultation and surgery approval. It is allowed to carry out online consultation to limit contact and exposure.
In severe cases where there is a risk of complications or death, if the hospital is not eligible to handle it, it is necessary to start an internal or inter-hospital red alarm to save the life of the patient and limit the risk of infection.
- Organize the on-site consultation (limit the participation from healthcare workers, only necessary people are allowed: The Department of Anesthesia and Intensive Care, Surgery Department; the General Planning Department, leadership boards of the hospital). If there are difficulties, online consultation may be applied.
- Preparation for transport the patient to the surgery suite: Test before the surgery, blood group, complete blood count, PT, aPTT, Fibrinogen; other assays shall be carried out latter.
- Pre-anesthesia assessment: Check the patient safety checklist that has been fully prepared before the pre-anesthesia assessment; pre-anesthesia assessment slip; name label of the patient and implement according to the following cases:
+ The highest level of emergency: Carry out medical examination right at the operating theatre after putting on the personal protective equipment. Minimize tests, avoid other unnecessary explorations.
+ In case where other explorations are required: It is necessary to consider to the advantages and disadvantages of that exploration and delay in surgery, if exploration is required. Exploration should be carried out in the operating theatre, if possible. Patient transportation must be restricted.
+ Emergency with delays: Medical examination shall be carried out in the place where the surgery indication is issued, in in the isolation room; personal protective equipment is required.
+ After the examination, the anesthesiologist shall notify the operating theatre to be poised for human resources and equipment.
- Notify for staff of the operating theatre to prepare, receive and transport the patient to the operating theatre:
+ Make a plan on the route to transport the patient to the operating theatre and the route to transport him/her to his/her room after the surgery.
+ The patient shall wear medical mask, medical cap, lay in bed, stretcher or wheelchair without talking when being transported. If the patient has respiratory distress, a safe aerosol-preventing manual ventilation (with HEPA filter to filter the exhaust gas) must be used, if endotracheal intubation is applied, it is required to install HEPA filter on the connection between the bag and the endotracheal tube.
+ Healthcare workers: Before moving, it is required to notify the operating theatre. Put on personal protective equipment, transport the patient to the operating theatre according to the defined route. Limit the use of elevators. In case of using elevators, the disinfection should be carried out immediately after using.
+ Quickly handover, fill in the patient’s surgical safety checklist and move the patient straight to the operating theatre.
4.2. At the operating theatre
- Surgical team must:
+ Conduct hand hygiene in accordance with the surgical hand hygiene procedure.
+ Wear sufficient personal protective equipment of levels 3 and 4.
+ Conduct surgical hand hygiene by alcohol-based surgical hand hygiene solution.
+ Wear a sterile surgical gown (with glasses or a face shield) when entering the operating theatre.
+ Wear 2 gloves (refer the Guideline on use of personal protective equipment).
- Set up an operating theatre for SARS-CoV-2 confirmed or suspected persons.
+ The operating theatre should be located at the end of the all or area with little/no impact on neighboring areas and should be isolated when needed.
+ Anteroom/antechamber where clothes and personal protective equipment are kept after being used.
+ One way: It is required to have additional regulations on antechamber in the operating theatre for SARS-CoV-2 patients.
+ Signs should be placed outside and in front of the operating theatre (surgery for COVID-19 patients).
+ Prepare adequate means, machinery, consumable supplies (Bag/bin containing wastes, linens and tools with symbol of infectious waste).
+ In case of using the positive pressure operating theatre or local air conditioning, it is required to turn off the air conditioner and turn on the exhaust air extraction and treatment system during the operation.
- Operate the operating theatre:
+ Limit people entry into the operating theatre: Anesthesiologist, surgeons; assistant surgeons; surgical technicians and 01 circulating technician. Additional human resources depending on each situation. Doctors and people with the most experience in the operating theatre shall be appointed to perform this surgery. Not to change any one during the surgery, except for compulsory case.
+ Limit to open the operating theatre’s doors during the surgery. The communication within and outside the operating theatre should be carrried out by radios, telephone or body languages, etc.
4.3. While the surgery is in progress
- The surgical team must re-check the patient for surgical safety after wearing personal protective equipment,
- Anesthesia staff:
+ Priority is given to regional anesthesia, if available. In case where the anesthesia is required, the technique of safe endotracheal intubation that avoiding SARS-CoV-2 spreading should be used.
+ Regional anesthesia is not recommended for patients with signs of lack of oxygen.
+ In case of indication, the regional anesthesia shall be carried out as usual, with protective equipment for staff and patients as mentioned above and it shall be carried out by the most experienced anesthesiologist.
+ The patient shall wear medical masks during the surgery.
+ In case where the anesthesia is required, anesthesia machines should be prepared:
✓ Place the filter at the inlet airway and in front of the ventilator's exhalation valve (see picture below), preferably a HEPA filter, if not, then either Safe star 80 filter (e.g. MP01785) or Safe star 55 filter (e.g. MP01790) is also acceptable.
✓ If there is a PetCO2 meter: Prefer the main-stream type, install the CO2 measurement cuvette after the filter (in the direction of the exhalation)
✓ If the side-stream PetCO2 is used: The exhaled air sample path should be fitted behind the filter.
Note: At the beginning of the anesthesia and endotracheal intubation:
- Store oxygen at a flow of 10 L/minute through a mask, tell the patient to avoid coughing, if possible:
+ Apply procedure of rapid endotracheal intubation, muscle relaxation Suxamethonium 2mg/kg, except for the case of contraindications.
+ Only use endotracheal intubation after making sure the patient has completely lost his/her cough reflex.
+ Priority is given to apply endotracheal intubation by camera, face of the person who carried out endotracheal intubation must be far from the mouth of the patient as much as possible, reducing the risk of infection.
+ Not to apply endotracheal intubation with flexible bronchoscope with on-site anesthesia, unless required
- If the patient drops SpO2 after stopping breathing, it is required to ventilate through the mask:
+ Make sure to keep the mask tightly closed, ventilated with low tidal volume (VT) or handbagging with a low tidal volume, to avoid letting the patient's exhaled air escape into the room.
+ Not use laryngeal mask, or non-invasive ventilation (NIV), unless it is indicated that a tight cuff must be pumped before using positive pressure ventilator.
- When the anesthesia ends and endotracheal withdrawal: Avoid letting the patient to cough and shoot exudate droplets around. Wear a surgical mask after withdrawing for the patient.
4.4. After the surgery
- Not monitor at the recovery room, the patient shall continue laying in the operating theatre until he is awake, and the post-surgery reception (or isolation room after the surgery) shall be notified for preparation to receiving the SARS-CoV-2 confirmed or suspected persons.
- During the transportation: The patient shall wear surgical mask, staff wear personal protective equipment, and use the defined route to transport.
- Make a prognosis about the risk to return to the intensive care unit and use a ventilator: Notify for the intensive care unit; transport the patient to the intensive care area for COVID-19 patients on a ventilator. Use additional sleeping pills and muscle relaxants before transporting. During the transportation, avoid removing the ventilator from the patient. In case of handbagging: Carrying out handbagging with a low tidal volume and gently, prevent the patient from coughing and fighting the ventilator.
- Make a prognosis about endotracheal withdrawal at the insensitive care unit, notification should be sent to the insensitive care unit. The endotracheal withdrawal shout be carried out and monitored at the operating theatre until the patient is stable.
- Members of the surgical team: Wear the personal protective equipment, and strictly comply with the procedures for taking off the personal protective equipment, because this is the stage with the highest risk of transmission.
+ Take off the surgical costumes immediately in the operating theatre and put them into the container for dirty linens.
+ Take off the personal protective equipment at the antechamber and put it into the infectious waste container and bring it out of the room and transfer to the safe infectious waste storage.
+ Always do hand hygiene before and after being in contact with the patient, tools and after remove gloves by antiseptic solution, then take off the personal protective equipment (see the Guidance on putting on and taking off personal protective equipment for more details).
+ Right after taking off personal protective equipment, it is not allowed to touch any part of the body or anything until carefully wash hands by soap or antiseptic solution.
- Waste and related linens after surgery must be put in a yellow plastic bag, sealed, wrapped with a second yellow plastic bag, sealed for treatment, before being taken out of the operating room, outside of such bags must be sprayed with chemicals sterilization (active chlorine with concentration of 0.1%).
- Post-surgery instruments shall be put in a sealed container and taken to the initial instrument handling area for treatment according to regulations, then put in the second container with the equipment symbol in COVID-19 patients, and transported immediately to the concentrated disinfection and sterilization unit, before leaving the operating theatre area, it is necessary to spray disinfection outside the container and call in advance the centralized disinfection and sterilization department, so that the department can receive and arrange safe handling.
- Immediately clean and disinfect the operating chamber, the adjacent area, and the aisles that the patient has just moved through according to the hospital operating theatre hygiene.
- Spray and disinfect surfaces immediately in the operating theatre with a solution containing 0.1% active chlorine or 2% hydrogen peroxide, the door shall be closed for at least 1 hour, then opened and wiped off new residues before reusing).
- Clean and disinfect equipment used for patients (including laryngoscope bulbs, mandrine, mask, ventilator and ventilator wire, monitoring and electric cylinder, etc.) with 0.1% active chlorine solution or 70 degree alcohol.
- Replace the PetCO2 tracking air intake wire, replace the filter on the airway.
4.5. Surgical record
Not take the surgical records (in paper form) into the operating theatre, the physician’s instructions and recording of medical records is carried out as same as the isolation area.
- Electronic medical records or electronic devices are recommended to record information during the surgery and contact with others for information exchanging, consultation and recording information with regard to treatment and care, etc. (for example tablet, scratch paper, board, etc.)
- Surgical report: It should be done on electronic medical records or software with connection inside and outside the operating area right after surgery.
- In case of using paper records: After completing the operating case, the staff shall take photograph all paper files used in the operating theatre, cut the paper files into many pieces and put them into the infectious waste trash bin.
- After leaving the operating theatre, the staff shall copy information stated in the medical records or update such information into the computer and upload into the electronic medical records, then print such information, sign with his/her name and put into the record as prescribed.
- With regard to drug sheet:
+ As above.
+ At the same time, the anesthesiologist and the recovery nurse shall check and record the drug sheet as photos, according to the procedure.
- The telephone is put in a plastic bag (before bringing it into the operating theatre), and after disinfection, the camera phone is used according to instructions (HPH-SOP-MED-ICC-017).
Note for the surgical team:
- After taking of all personal protective equipment in accordance with instructions, they must go to the bathroom for staff: Take a bath with hot water, wash mouth and change new clothes.
- Members of the surgical team shall stop working for the remainder of their working shift.
- After the patient gets the SARS-CoV-2 testing result:
+ If the result is positive (+): Isolate in accordance with the agency controlling the pandemic.
+ If the result is negative (-): Continue to implementing daily jobs.
- Make a list of surgical team, on a daily basis, check temperature and record signs of coughing, fever, sore throat within 14 days for members of the surgical team.
5. Inspection and surveillance
- Infection Control Department, Nursing Department, Head of Departments and Head Nurses of relevant departments shall be responsible for training, inspecting, monitoring and urging the strict implementation of regulations and instruction, and procedures for operating patients with confirmed or suspected SARS-CoV-2.
- On a daily basis, supervise the healthcare workers’ observance of procedures on receiving and preparing patients to be operated, transporting patients, putting on personal protective equipment, implementing environmental hygiene and protect safety for the team operating for patients with confirmed or suspected SARS-CoV-2.
- Surveillance results should be immediately given to the supervised person and reported to the department head and the hospital leader.
TREATMENT OF CORPSE OF SARS-COV-2 CONFIRMED OR SUSPECTED PATIENTS
1. Objectives
- The healthcare worker must duly treat and strictly comply with the process and regulations on treatment of corpse of SARS-CoV-2 confirmed or suspected patients.
- Prevent SARS-CoV-2 infection to healthcare workers, patients’ families, funeral attendees and the community.
2. Scope of application
- The Department of Pathological Surgery, the Mortuary and clinical departments where a SARS-CoV-2 confirmed or suspected patient died.
- Healthcare workers and patients’ families who have direct contact with the corpse of a SARS-CoV-2 confirmed or suspected patient.
3. General principles
- Absolutely apply all measures of standard prevention and prevention by isolation over contact or droplets when a corpse is being transported and treated.
- Only authorized healthcare workers and patient families who have been educated and process of prevention and are fully equipped with appropriate personal protective equipment can join the treatment of the corpse of a SARS-CoV-2 confirmed or suspected patient.
- Ensure not to spread pathogen during the process of treatment, transportation, cremation and burial of corpse of a SARS-CoV-2 confirmed or suspected patient.
- Move the other isolated patient(s) in that room (if any) to another isolation room before treating the corpse.
- The corpse of SARS-CoV-2 confirmed or suspected corpse must be cremated. Burial can only be applied when cremation is impossible.
- A corpse must be shrouded as soon as possible and must be cremated or buried within 24 hours since the time of death.
- All waste generated during the handling, transportation, cremation or burial of a corpse of a SARS-CoV-2 confirmed or suspected person must be disposed of as infectious waste.
4. Means
4.1. Means of transport, preservation and handling of corpses
- The coach or stretcher used to transport a corpse must be disinfected right after each time of use.
- Dedicated bags for corpse containing must be available. In case of not, there must have waterproof nylon bags having zip fastener, mechanically durable, having appropriate size and disposable bed-sheets.
- Cool room used for corpse storage or corpse keeping must be equipped with basin for hand-wash, chemical for disinfection of surface, floor and hygiene utensils for disinfection of surface.
4.2. Personal protective equipment, hand hygiene and waste collection
At the clinical department where there is a SARS-CoV-2 confirmed or suspected patient and at the Mortuary there must always have utensils for infection prevention practice, including:
- Hand hygiene means: Hand wash soap and alcohol-based hand hygiene solutions.
- Personal protective equipment: are those disposable things (gloves, paper hats, medical masks, gowns, goggles, aprons). All of them must be waterproof.
- Utensils for waste collection: yellow bag and bin with size big enough to collect after-use personal protective equipment.
- Chemical disinfectant: a solution with 0.1% active chlorine.
- Utensils for environmental hygiene and disinfection: Towel used to clean surface, hand sprayer or hand spraying machine.
5. Execution
5.1. At the unit where a SARS-CoV-2 confirmed or suspected patient died
As soon as a SARS-CoV-2 confirmed or suspected patient died, the healthcare staff who directly treat and care that patient must execute the following tasks:
- Not to arrange another patient (including a SARS-CoV-2 confirmed or suspected patient) in the room having the corpse. In case that room has another patient, that patient must be moved to another room immediately.
- Make a telephone call and send a written request to ask the Mortuary to assign staff to come and transport the corpse to the Mortuary.
- Unauthorized persons and patient families are strictly prohibited to get into the room.
- Explain the patient families about the risk of infection and instruct them the regulations and the infection prevention measures that must be applied when having contact with the corpse and during the shrouding and visiting.
- No things are allowed to be brought out of the room if this room has not been disinfected for the last time.
- While waiting for the Mortuary staff to come and transport the corpse, the department’s staff must cover the corpse with a bed sheet and must clean all the surfaces where the patient lies with solution of 0.1% active Chlorine.
- The Mortuary staff must wear all personal protective equipment during corpse treatment. Details of personal protective equipment for corpse treating staff are mentioned in Appendix 3.
- The corpse is isolated in the following steps:
+ The corpse must be closely covered in a corpse bag with waterproof material lining inside to prevent the outward leakage of body fluids.
+ Spray disinfectant chemical of 0.1% active Chlorine outside the first layer of bag. Do the same with the second layer of corpse bag. The corpse bag must be made from waterproof material which is opaque, firm, and not easily torn/pierced; the bag wall must be ≥ 150μm in thickness; the zip fastener must be tight and firm.
+ In case there is no corpse bag, the corpse must be closely wrapped up with 02 thick layers of cotton fabric. Spray disinfectant chemical of 0.1% active Chlorine outside the first nylon layer of bag. Do the same with the second layer of nylon.
+ After closely covered the corpse in a corpse bag, use the card or sticker with the biohazard symbol (according to the Circular 02/2009/TT-BYT dated May 26, 2009 of the Ministry of Health guide hygiene in funeral and cremation activities) outside the bag.
+ Spread out a clean bed sheet on the corpse transporting vehicle, put the corpse on the clean bed sheet, move towards the room and put off personal protective equipment (put inside the patient room), disinfect hands and get out of the patient room.
+ The Mortuary staff wearing all personal protective equipment receives the corpse at the outer of the patient room and transport it to the Mortuary.
- Repeat disinfecting the entire patient room and the corridor after treatment.
- During the time since the death of the patient until the corpse is brought out, the healthcare workers at the department where the patient died must watch and advise all persons getting into the patient room to duly execute the regulations on infection prevention.
5.2. Transport the corpse from the patient room to the Mortuary
- During the corpse transportation, the healthcare workers must fully wear personal protective equipment (surgical mask, gloves, paper gown, hat and boots). Details of personal protective equipment for corpse treating staff are mentioned in Appendix 3.
- Transport the corpse on the isolation way and the disinfection spraying must be done immediately after; In case the corpse is transported in the elevator, other person(s) must not be accompanied; if the patient family request an accompaniment, he/she must fully wear personal protective equipment. The corpse should not be transported through crowed places.
- Right after the corpse is moved into the storage room, the Mortuary staff transporting it must spray the vehicle with disinfectant solution of 0.1% active Chlorine and must not use it in 30 minutes, then put off personal protective equipment as order, discard them into the yellow nylon bag, carefully wash hands and do personal hygiene before doing other tasks.
5.3. Shrouding process
The shrouding process must comply with the special procedure of dangerous epidemic:
- Shrouding must be executed as soon as possible.
- Corpse shrouding must be executed at the Hospital Mortuary. The shrouding attendees must be minimized.
- The staff directly executing shrouding must fully wear personal protective equipment (surgical mask, gloves, paper gown, hat and boots). Clean hands with alcohol-based solution and carefully wash hands with soap.
- The patient families must absolutely not be allowed to visit the corpse during the time of storage until the shrouding is completed.
- Corpse shrouding process:
+ On the bottom of the coffin, put a nylon sheet large enough to cover the corpse.
+ Wrap the corpse closely with the underlying nylon sheet.
+ Tightly shut the coffin. Check and seal all coffin gaps (if any) with waterproof adhesive tape.
- The Funeral Home staff must spray disinfectant over the entire surface of the shrouding room and the coffin surface with solution of 0.1% active Chlorine.
+ Put off all personal protective equipment (surgical mask, gloves, paper gown, hat and boots) and discard them into the yellow nylon bag.
+ Clean hands with alcohol-based solution and carefully wash hands with soap.
+ Have shower and body cleaning before doing other tasks.
5.4. Transporting of the corpse
- Notify in advance the Centers for Disease Control of the province or city where the body will be moved.
- Complete the body transfer file as requested by the preventive medicine agency.
- Transport the corpse directly to the cremation or burial place (in the case where there is no cremation in the province/city) according to the plan agreed with the local Center for Disease Control. The corpse must be transported in a dedicated vehicle directly to the cremation or burial site. Patient families must not gen on the corpse-carrying vehicle.
- The corpse-carrying vehicle driver must fully wear personal protective equipment.
5.5. Visiting and treatment of the corpse of SARS-CoV-2 confirmed or suspected patients
- Visitors are not encouraged. Visitors must wear mask, must not touch the coffin and must have their hands cleaned with alcohol-based solution after visiting.
- The corpse of a SARS-CoV-2 confirmed or suspected patient should be cremated or buried as soon as possible. It must not be laid more than 24 hours since the moment of death.
- Right after the coffin is transported to the cremation site or burial site, the coffin-carrying vehicle must be disinfected with disinfectant solutions that are certified to be circulated by the Ministry of Health.
- In case there is a demand to transport the corpse, remains across the border, it must be executed under the Decree 89/2018/ND-CP dated June 25, 2018 by the Government stipulating details to execute articles of the Law on Prevention and Control of Infectious Diseases in health quarantine at border.
6. Examination, supervision and duties
- The Department of Infection Control, Nursing Department, Heads of Department and Head Nurses of the relevant departments have the duty to train, examine, supervise and encourage the strict execution of corpse treatment process and regulations on SARS-CoV-2 confirmed or suspected patient.
- The unit where the patient died: ensure to abide by regulations of infection prevention and control at the area under its management.
- Funeral Home (or Department of Surgery): receive and transport the corpse to the Mortuary, have it shrouded and organize the visit and treatment of corpse as regulated.
- The Transporting Unit: arrange vehicle to transport the corpse and implement the regulations during the time the corpse is being transported to cremation site (or the cemetery). A certain number of personal protective equipment should be available to transfer to the patient families for use if necessary.
- The General Planning Department: shall monitor the examination, reception and report to ask for the Hospital Management to resolve problems arising during the execution of this regulation.
- Make the list of all healthcare workers, patient families, etc. who attend to treat and shroud the corpse for report and monitoring within 14 days as regulated and instruct them the symptoms that require detection, report and examination.
GUIDELINES ON PREVENTION OF SARS-COV-2 INFECTION OVER PATIENT FAMILIES AND VISITORS
Patient families and visitors are the subjects having risks of being confirmed and spreading the source of infection to the community. All health facilities must develop materials for training, education and communication for compliance with measures to prevent infection including minimizing visits and providing personal protective equipment for these subjects.
1. Objectives
- Preventing infection to visitors, patient families when contacting the persons confirmed or suspected of SARS-CoV-2.
- Train, educate and propagate measures to prevent and control infection when visiting and taking care of patients during epidemic seasons.
- Ensure the safety for community to avoid wide spread of SARS-CoV-2.
2. Principles for execution
- Absolutely do not let patient’s family or visit when the confirmed or suspected persons are under isolation for treatment and monitoring at medical examination and treatment establishments.
- Do not permit visit at the isolation area when performing procedures which can create close aerosols, droplets to prevent dangerous infection.
- Maximally limit visit to the isolation area to prevent spread of disease to community.
- In case of compulsory visit or contact with patients, all visitors must comply with the preventive principles at the isolation area. The visitors should be instructed on how to wear or remove the personal protective equipment before coming to the isolation area.
- Upon permission for patient visiting, do not let visitors closely contact patients (within 2 meters).
- Children of breastfeeding mothers confirmed or suspected of SARS-CoV-2 must be isolated from their mothers to prevent spread and do not let children breastfeed their mothers until the primary doctor gives indications.
When going out of the isolation area after visiting, comply with the procedures for removal all personal protective equipment and hand hygiene properly before leaving the isolation area. Provide all personal information and keep regular contact with the medical authorities as instructed for post-contact exposure monitoring.
- There should be healthcare workers escorting and guiding visitors to strictly comply with regulations and write names for further monitoring.
3. Subjects and scopes of application:
All visitors, relatives of the patient, and healthcare workers in close contact with the patient at all times of quarantine and all isolated wards (from the place where the patient is suspected, infected and treated for a severe patient)
4. Implementation
4.1. Before entering isolation room
- Patient families and visitors before entering the isolation area must be instructed and properly wear and remove the personal protective equipment, especially paying attention to the personal protective equipment to prevent infection via respiratory tract (wear and remove medical mask, N95 respirator).
- Healthcare workers must be presented in the buffer room area to instruct visitors to follow steps of wearing and removing personal protective equipment and monitor the visitors’ actions.
- Healthcare workers must check the compliance with instructions and understanding of requirements on prevention of infection before allowing visitors into the isolation area.
4.2. In the isolation room
- All visitors must comply with the instructions and supervision of the healthcare workers in the isolation ward, including:
+ Do not bring food or objects from outside into the isolation ward.
+ Not to arbitrarily touch any objects in the isolation ward,
+ Do not have close or direct contact with the patient (hug, kiss, shake hands).
+ Keep a distance of at least 2 meters from the patient.
+ In the treatment area of serious patients with invasive procedures, do not visit, only stand in the buffer room or outside the isolation room to monitor through glasses or cameras (if for professional and affectional reasons)
4.3. Going out of isolation room
- Remove all protective costumes as instructed by the healthcare workers right at the buffer area, clean hands in and before leaving of isolation area.
- Do not bring any item or personal protective equipment in the isolation area after use to other places.
- Make a list of close contact with persons confirmed or suspected of SARS-COV-2 and inform the local preventive medical agencies for proper health monitoring and handling.
- Give advice to patient families and visitors to proactively declare all personal information for monitoring and self-monitoring of symptoms after leaving the isolation area within 14 days. When there are abnormal signs of health, immediately go to the nearest medical facility for report and advice.
- Inspection and surveillance: Department of infection control, Nursing Department, Heads of Department and Head Nurses of relevant departments are responsible for training are responsible for training, inspection, surveillance and urging of the strict compliance with procedures and regulations on involvement in care for a SARS-CoV-2 confirmed or suspected patient, includes monitoring whether healthcare workers training, guidance, and supervision of family members and visitors or not.
PREVENTION OF SARS-COV-2 INFECTION FOR HEALTHCARE WORKERS
Healthcare workers are at high risk of being infected with SARS-CoV-2 during the care and treatment of patients and provide other services in medical examination and treatment establishments. All medical examination and treatment establishments should to develop and implement preventive measures suitable to the risk of SARS-CoV-2 infection for each region and each type of healthcare worker to make sure that infection does not occur among healthcare workers.
1. Objective
- Ensure safety for healthcare workers and their families.
- Ensure human resources for epidemic prevention in particular and medical examination and treatment in general.
2. Principles for execution
Protection of the healthcare worker from physical and biological hazards in the care of a SARS-CoV-2 confirmed and suspected patient:
- Ensure the implementation of dark standards of safety in patient care, prevention and in all health care facilities throughout the health system.
- Ensure that personal protective equipment is available at all times, relative to the role and task to be performed, in appropriate and appropriate quantities and of acceptable quality. Ensure adequate storage of personal protective equipment in the buffer rooms or areas (always enough for patient care, isolation, and examination areas, etc.). Ensure adequate training in the use of appropriate personal protective equipment and safety precautions.
- Ensure a full range of environmental care services such as water, sanitation, disinfection and adequate and safe ventilation at all health facilities.
- Ensure vaccination for all healthcare workers at risk of transmitting infectious diseases with high pandemic risk and high mortality that can be prevented with vaccines, including Hepatitis B and seasonal influenza, as appropriate with the national immunization policy. In the context of an emergency response, priority is given to the healthcare worker access to newly licensed and available vaccines.
- Provide adequate resources to prevent injury and harmful exposure to chemicals and radiation to healthcare workers; provides ergonomically designed equipment and work stations to minimize musculoskeletal injuries and falls.
- Health facilities must perform streaming and screening to detect early and promptly isolate SARS-CoV-2 confirmed or suspected people in order to limit the risk of infection for healthcare workers and patients.
- Risk assessment, timely detection and isolation of SARS-CoV-2 confirmed or suspected healthcare workers.
- Training for all healthcare workers on how to report health declaration, how to recognize risks and prevent COVID-19 infection, clinical manifestations of the disease and regulations related to timely diagnosis and isolation of SARS-CoV-2 confirmed or suspected healthcare workers.
3. Subjects and scopes of application
- Healthcare workers who directly provide care at the treatment and care units for SARS-CoV-2confirmed or suspected patients.
- Healthcare workers indirectly takes care of the patient, including healthcare workers implement other related services in the medical examination and treatment establishments.
4. Implementation
4.1. Organize the streaming, screening and isolation of SARS-CoV-2 confirmed or suspected patients
The streaming, screening and isolation of SARS-CoV-2 confirmed or suspected patients helps control the source of infection in medical examination and treatment establishments, and also helps the healthcare worker to properly recognize the risk of infection in order to apply appropriate preventive measures.
- Patients at high risk of SARS-CoV-2 (patients with clinical symptoms and/or patients with epidemiological factors) should be streamed and screened immediately when they come to the medical examination and treatment establishments.
- Patients with confirmed or suspected or pending diagnosis of COVID-19 should be isolated in the screening area, in the isolation room of clinical faculties or in gathered isolation areas of medical examination and treatment establishments.
4.2. Prevention of exposure to SARS-CoV-2
4.2.1. Prevention of SARS-CoV-2 exposure when directly taking care of a SARS-CoV-2 confirmed or suspected patient
This content applies at the reception, screening and isolation area for SARS-CoV-2 confirmed or suspected people, including:
- Always wear full personal protective equipment when receiving, screening and taking care of a SARS-CoV-2 confirmed or suspected person.
- Always use proper personal protective equipment during contact and care for patient, including the procedures of wearing and removing personal protective equipment, changing personal protective equipment when necessary.
- Always follow proper hand hygiene times.
- Wipe and disinfect surfaces often in contact with hands at least 3 times/day.
4.2.2. Prevention of SARS-CoV-2 exposure when collecting diphtheria specimens and when performing aerosol airway manipulations in SARS-CoV-2 confirmed or suspected patients.
This content applies at the area where the diphtheria specimens are collected and the isolation of SARS-CoV-2 confirmed or suspected patients under the Resuscitation and Emergency Department, including:
- Healthcare workers needs to be proficient in how to take samples safely and
- Wear sufficient personal protective equipment (level 4 anti-epidemic protection including N95 respirator, goggles or mask) when taking samples of a SARS-CoV-2 person.
- Use proper personal protective equipment during contact and care for patient, including the procedures of wearing and removing personal protective equipment, changing personal protective equipment when necessary (Note: wear 2 gloves when collecting samples and when remove, be careful not to infect yourself).
- Always follow proper hand hygiene times.
- Wipe and disinfect surfaces often in contact with hands at least 3 times/day.
- All wastes generated during sampling are infectious wastes that must to be collected, transported and handled safely.
- All healthcare workers when taking samples must know how to handle professionally occupational accidents caused by blood and biological fluids, accidents of needles and sharp objects during the sample collecting process.
4.2.3. Prevention of SARS-CoV-2 exposure when directly taking care of other patients in medical examination and treatment establishments.
This content applicable to all clinical departments when providing healthcare for normal patients, including:
- Always wear person protective equipment. Wear a medical mask when taking care, in direct contact (within 1 meter) with all patients, wear an N95 mask when performing procedures capable of creating aerosols.
- Always use and properly process masks during contact and care, including the process of wearing and removing the mask, changing the mask when necessary (when it is torn, moist, and contaminated with biological fluids).
- Implement to proper hand hygiene times when taking care of patients and other indications when cleaning the environment, providing nutritional services, pharmaceuticals, providing sterile equipment.
- Sanitize and disinfect surfaces in care areas for a SARS-CoV-2 confirmed or suspected patient with frequent hand contact at least 3 times a day and when required.
- Classification and disposing of wastes safely and according to regulations (classification, collecting, transporting, and final treatment).
4.2.4. Prevent exposure to biological secretions of patients
This content applies in all clinical departments to all healthcare workers directly taking care of patients, including:
- Implement vaccination for healthcare workers every year, before common epidemics according to regulations.
- Have procedures to prevent exudate (blood, oropharynx) from splashing into the eye, nose, and mouth mucosa and into not intact skin and training healthcare workers to handle it.
- Provide sufficient guidance on the use of personal protective equipment, hand hygiene, environmental surface cleaning (Details of contents to prevent exposure to biological secretions of patients in the instructions on Prevention standard).
4.3. Risk assessment of exposure, early detection, and timely isolation of COVID-19 confirmed or suspected healthcare workers
- All healthcare workers directly taking care of, transporting, and taking hydrocephalus specimens of a SARS-CoV-2confirmed or suspected patients should be periodically assessed for the risk of COVID-19 exposure according to Form 1 (Appendix 12).
- All healthcare workers at high risk of exposure (healthcare workers not always performing at 5A-G and 6A-F) should be isolated for 14 days and examined for COVID-19.
- Train staff on how to self-assess, detect signs and symptoms of acute respiratory infections such as fever, cough, difficulty breathing, and immediately notify unit leaders for screening and testing for COVID -19.
- Isolate healthcare workers in contact with COVID-19 patients and people returning from the epidemic area according to the isolation regulations of the National Epidemic Control Board.
- During the quarantine period, healthcare workers should be provided with counseling and psychological support and are entitled to full salary as well as other epidemic prevention regimes according to regulations.
- After the quarantine period expires, the healthcare workers should be reviewed and retrained on practical measures to prevent COVID-19 infection before returning to care for the patient.
4.4. Training to improve knowledge and skills to prevent COVID-19 infection
All healthcare workers must be trained on the following main contents:
- Updated information on epidemic situation, transmission routes, COVID-19 prevention measures.
- Clinical symptoms and how to recognize COVID-19 infection.
- How to assess and determine risk factors for COVID-19 infection.
- Isolation regulations related to COVID-19.
4.5. Temporary retention of exposed healthcare workers
- There must be a temporary isolation ward for healthcare workers to wait for at least 14 days for SARS-CoV-2 test results.
- Have sufficient facilities, materials and consumable materials for the healthcare worker during the stay.
- Provide nutritious meals for healthcare workers during their stay.
- Assign appropriate work for healthcare workers while waiting for test results to return.
- Health facilities must have an adequate policy for management of exposed healthcare workers, rest, salary, and insurance.
+ Implement isolation at the unit to ensure the maintenance of medical examination and treatment. In case medical facilities can arrange a hotel to stay outside the working time for healthcare workers, follow the instructions in Decision No. 1462/QD-BYT dated March 30, 2020.
+ If he/she is not present at the medical examination and treatment establishment when establishing the isolation area, he/she shall notify such individual for consultation on health monitoring, examination, and treatment according to regulations.
+ Monitor symptoms systematically. Monitoring temperature 2 times/day for all medical staff working in the area (when needed, should check X-rays). Time of isolation period: At least 14 days. In case there is any symptom, immediately notify the leader
4.6. Criteria for medical personnel to return to work after positive for SARS-CoV-2
• Fever goes away
• Better clinical symptoms, and
• PCR results are negative at least 2 times when taking oropharyngeal samples at least 24 hours apart
In case there is no symptom
• PCR results are negative at least 2 times when taking oropharyngeal samples at least 24 hours apart
5. Inspection and surveillance
- The Department of Infection Control, Nursing Department, Heads of Department and Head Nurses of the relevant departments have the duty to train, examine, supervise and encourage the strict execution of procedures and regulations for implementing isolation procedures of healthcare workers
- The General Planning Department, Department of Quality Control: shall monitor the examination, reception and report to ask for the Hospital Management to resolve problems arising during the execution of this regulation.
- Content of surveillance:
+ 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.
PREVENTION AND CONTROL OF COVID-19 AT NUTRITION AND CATERING UNITS
1. Objectives
- Prevent risks of SARS-CoV-2 exposure for staff at nutrition and catering units (Hereinafter referred to as staff).
- Early detect and promptly isolate SARS-CoV-2 confirmed or suspected staff.
- Ensure food safety and hygiene and safety in handling utensils, equipment for processing, storage and distribution of food and beverage.
- Ensure safety of environmental surfaces at nutrition and catering units.
2. Principles of implementation
- All staff must be trained on detection methods and measures for prevention of SARS-CoV-2 transmission. To arrange checkers for early detection and prompt isolation of SARS-CoV-2 confirmed or suspected staff.
- Processing of food and beverage in hospital must comply with regulations on food safety and hygiene.
- All utensils, tools, equipment used for processing, storage and distribution of food and beverage must be handled according to Guidance on tool disinfection and sterilization of the Ministry of Health. The use of disposable utensils and tools are prioritized at isolation areas for patients with confirmed or suspected SARS-CoV-2. Disposable utensils must be collected, transported and destructed immediately after use as infectious medical waste. Reuse of reusable utensils must strictly comply with procedures of disinfection and sterilization of equipment used for treatment and care for patients with confirmed or suspected SARS-CoV-2.
- Environmental surfaces of nutrition and catering units must be cleaned and disinfected in accordance with the Ministry of Health’s Guidance on surface hygiene. Frequently touched surfaces with higher risk of contamination must be cleaned at least 02 times/day.
3. Subjects and scopes of application
- Staff of nutrition and catering units.
- Utensils, equipment used for processing, storage and distribution of food and beverage.
- Environmental surfaces at nutrition and catering units.
4. Means
- For hand hygiene: alcohol-based hand sanitizer, hand washing soap.
- For measuring body temperature: electronic thermometer, sensor thermometer
- Personal protective equipment: are those disposable things (gloves, paper hats, medical masks, gowns, goggles, aprons). All of them must be waterproof.
- Utensils for environmental surface hygiene: wipes and mop pads for cleaning surfaces, chemicals disinfecting surfaces according to regulations.
- Vehicles for waste collection and transportation: Bags, bins as defined with size suitable for waste collection.
- Facilities for sterilizing reusable utensils, equipment (See Procedures for handling of medical instruments)
5. Implementation
5.1. Prevent SARS-CoV-2 exposure
- Staffs must be trained on detection methods and measures to prevent SARS-CoV-2 transmission
- Staffs must comply with regulations on hand washing times as follows:
+ Before and after the food processing.
+ Before and after delivery and distribution of food and beverage.
+ After cleaning environmental surfaces, utensils and equipment in the food processing area.
+ After touching utensils and equipment used for storage, processing, preservation, distribution and transportation of food.
+ After going to the toilet, or when hands are dirty.
+ After blow your nose or cough.
- Comply with the instructions and techniques of putting on and taking off personal protective equipment (gloves, masks, gowns).
- All staff with signs, symptoms of acute respiratory infections must be entitled to leaves to take a medical examination at consulting room to be screened and isolated according to regulations.
5.2 Early detect and promptly isolate staff with confirmed or suspected SARS-CoV-2
- Train staff to evaluate and detect by themselves signs of acute respiratory infections such as fever, cough and shortness of breath appears and promptly notify the leader of nutrition and catering unit.
- Arrange staff checking and evaluating signs, symptoms of acute respiratory infections of all of staff working in nutrition and catering unit before each working day/shift. Checkers shall guide staff with signs/symptoms of acute respiratory infections to take a medical examination at consulting room to be screened and isolated according to regulations. Areas for checking, evaluating signs, symptoms of acute respiratory infections must be always equipped hand hygiene equipment. Checkers wear person protective equipment according to regulations and use thermometers not in direct contact with the body (electronic thermometers or remote thermometers) to check the body temperature. The distance between two checkers at checking area must be at least 02 m. The number of healthcare workers whose signs and symptoms of acute respiratory infections are checked and evaluated must be daily monitored to make sure that workers present in a working shift are not left out.
5.3. Prevent SARS-CoV-2 exposure
- Staffs must be trained on detection methods and measures to prevent SARS-CoV-2 transmission
- Staffs must comply with regulations on hand washing times as follows:
+ Before and after the food processing.
+ Before and after delivery and distribution of food and beverage.
+ After cleaning environmental surfaces, utensils and equipment in the food processing area.
+ After touching utensils and equipment used for storage, processing, preservation, distribution and transportation of food.
+ After going to the toilet, or when hands are dirty.
+ After blow your nose or cough.
- Comply with the instructions and techniques of putting on and taking off personal protective equipment (gloves, masks, gowns).
- All staff with signs, symptoms of acute respiratory infections must be entitled to leaves to undergo a medical examination at consulting room to be screened and isolated according to regulations.
5.4. Food hygiene and safety
- Utensils and equipment for processing food and beverages (knives, cutting boards, bowls, dishes, countertops, etc.) should be cleaned after each use.
- Wash fruits and vegetables under running water, including the one whose peel is not eaten. Use a clean brush to scrub food with hard shells.
- Clean the lids of food containers before opening, for canned food.
- Food must be cooked before being served to eaters.
- Cool hot food by a rapid cooling method (such as placing in the refrigerator, soaking in an ice bath or other cooling methods).
- Minimize time to store and distribute food at a temperature favorable for growth of microorganisms (5-57°C).
- Stop providing buffet food services, providing shared food, drinks and water supply during the COVID-19 epidemic.
- The handler of food and drink should keep a distance of 02 m from the receiver. When receiving food and drink at the restaurant and canteen, line up and maintain a distance of 02 m. Promote supply of meals “without in-person contact”. Food is delivered to the centralized food distribution place at the time which has been notified in advance via phone, text message or other means of communication and people shall take food and drink by themselves at the concentrated distribution place.
- The truck serving food transportation is equipped with food heating/cooling equipment to avoid spoilage of food during transportation. Pack tightly food and drink during transportation.
- Keep ready-made food, raw and cooked foods separately.
5.5. Handling of reusable utensils
- Healthcare workers must instruct persons with confirmed or suspected SARS-CoV-2 to put their utensils after use into the reusable utensil container and their leftover food into infectious waste container.
- Healthcare workers collect the reusable utensils and put them into closed container with label of eating utensils of persons with confirmed or suspected SARS-CoV-2 and then move them to the Department of Nutrition (or Department of Infection Control) for proper handling.
- When handling the eating utensils, staff should wear person protective equipment as instructed.
- The liquid from leftover food, water will be collected as infectious waste of the isolation area properly before being transported to the treatment place.
- Transport the reusable tools to the centralized handling area, store in bags, containers with lid. Do not carry it in your arms and on shoulders with bare hands.
- Soak food and drink containers after use in a solution of 0.1% of active chlorine active ingredients for 10 minutes-20 minutes to disinfect them. Completely immerse such utensils in disinfectant solution. In the absence of chemical disinfectant, it is possible to boil the utensils for 10 minutes.
- Encourage the use of automatic utensil washing machines with closed doors and operation with chemical and temperature cycles, then automatically drying for types of utensils (including many different types) for people with confirmed or suspected SARS-CoV-2.
5.6. Cleaning of environmental surfaces
- Surface cleaning staff must wear personal protective equipment according regulations.
- Frequently touched surfaces with higher risk of contamination must be cleaned at least 02 times/day.
- Use surface cleaning chemicals according to Instruction on cleaning of environmental surfaces in medical examination and treatment establishments of the Ministry of Health issued under the Decision No. 3916/QD-BYT dated August 28, 2017 by the Minister of Health.
6. Inspection and surveillance
- Department of Infection Control, Nursing Department, relevant Heads of Department and Head Nurses are responsible for training, inspection, surveillance and urging of strict compliance with the procedures and these regulations.
- Nutrition and catering units: ensure the compliance with regulations of areas under their management.
- The General Planning Department: monitor the implementation, receive, and report to ask for the hospital’s management board to resolve, problems arising during the execution of this regulation.
CONTROL OF VENTILATION AT EXAMINATION AND TREATMENT AREAS FOR COVID-19 PATIENTS
1. Objectives:
- Ensure the air circulation rate of 12 ACH at examination and treatment areas for people with confirmed or suspected SARS-CoV-2 to prevent transmission of SARS-CoV-2 through the air.
2. Scope of application:
- Examination and treatment unit for people with confirmed or suspected SARS-CoV-2.
- Healthcare workers, caregiver of people with confirmed or suspected SARS-CoV-2.
3. General principles:
- Medical examination and treatment facilities must have a plan on assessment and maintenance of the ventilation system, ensuring the following 03 principles:
+ Ventilation speed: the quantity and quality of the outdoor air delivered into the spaces of the examination and treatment areas according to the Standards specified in this Guidance.
+ Airflow direction: The direction of air movement must be from clean to less clean areas.
+ Airflow distribution: Outside air must be effectively brought to every part of the space in the examination and treatment area for COVID-19 patients and airborne pollutants in each part of the space should also be removed effectively.
+ Air Change Rate Per Hour (ACH): ACH to be determined in each room of the examination and treatment area according to Standards specified in this Guidance.
- Have specialized staff trained to operate, inspect and maintain the ventilation system.
4. Vehicles
- Ventilation fan system (ventilator, exhaust fan).
- Air filter.
- Wind turbine.
- Radiator grille (or air blower).
- Negative pressure ventilation system.
5. Execution
5.1. Ventilation system design
Ventilation is the measure of moving outdoor air into a building or a room and distributing the air within the building or room. The main purpose of ventilation in a building is to provide healthy air for breathing by both diluting the pollutants originating in the building and removing the pollutants from it. There are three basic elements related to ventilation:
- Ventilation rate - the amount of outdoor air that is provided into the space, and the quality of the outdoor air.
- Airflow direction - the overall airflow direction in a building, which should be from clean zones to dirty zones; and
- Air distribution or airflow pattern - the external air should be delivered to each part of the space in an efficient manner and the airborne pollutants generated in each part of the space should also be removed in an efficient manner.
Based on climatic conditions, wind direction, resources and needs, each medical examination and treatment establishment shall select at least one of the following three types of ventilation systems (see Appendix 13):
5.1.1. Natural ventilation: winds and thermal buoyancy force. Thermal buoyancy force is due to indoor and outdoor air density differences. Thermal human activities raise the air temperature in the building, at a high temperature, the gas will lighten and rise high and an area with low barometric pressure is formed. Cold outdoor air that has a higher barometric pressure will be supplied through purpose-built openings include windows, doors, solar chimneys, vents. The wind pressure is created when the wind is blowing into a building, causing a positive pressure on the windward side and a negative pressure on the leeward side of buildings. Cause of the pressure difference, the air will enter any windward opening and be exhausted from any leeward opening at low pressure positions. Therefore, open the door in the direction of the main cool air and the outlet on the opposite side. Polluted air in a room should be exhausted directly outdoor, kept away from vents, care and treatment areas, or crowds. Natural ventilation depends on the weather conditions. When weather conditions are not suitable for natural ventilation, mechanical ventilation or mixed ventilation should be considered to replace.
5.1.2. Mechanical ventilation: Use ventilation fans for mechanical ventilation. Fans can either be installed directly in windows or walls or installed in air ducts for supplying air into, or exhausting air from, a room. In the examination and treatment area for patients with suspected or confirmed SARS-CoV-2, it is necessary to use a negative pressure mechanical ventilation system to supply outdoor air to the patient room.
5.1.3. Mixed-mode ventilation: relies on natural driving forces (winds and thermal buoyancy force) to provide the desired flow rate. It uses mechanical ventilation when the natural ventilation flow rate is too low. With support of mechanical ventilation through a properly installed fan system to supply clean air and exhaust polluted air, it will increase ventilation rates in rooms housing patients with airborne infection. However, be careful when installing the system of ventilation fans. Ventilation fan should only be installed at the place so that the air in a room can be sucked directly out through a wall or roof. The size and number of exhaust fans depends on the targeted ventilation rate per hour, and must be measured and tested before use. Problems associated with the use of exhaust fans include installation difficulties (especially for large fans), noise (particularly from high-power fans), increased or decreased temperature in the room and the requirement for non-stop electricity supply. If the environment in the room causes thermal discomfort, spot cooling or heating systems may be added.
For a medical examination and treatment establishment that has not condition for equipment of appropriate natural or mechanical ventilation system, the following solutions can be considered:
- Install exhaust fans: Room air can be exhausted directly to the outdoor environment. The size and specifications of exhaust fans depends on volume of the room and the targeted ventilation rate. The exhaust fan is not installed near the air inlet. If there is an increase or decrease in temperature, a heating or cooling system or a ceiling fan can be added.
- Install wind turbines that do not require electricity and provide a roof-exhaust system increasing airflow in a building.
- Install high efficiency particulate air filter (HEPA filter): Reduce concentrations of polluted aerosol in separate spaces. However, the evidence for the effectiveness of the HEPA filter in preventing SARS-CoV-2 infection remains limited. Medical examination and treatment establishments must comply with instructions of the manufacturers when using HEPA filter.
5.2. Standard on ventilation
5.2.1. Natural ventilation
- For an isolation room for people with suspected or confirmed SARS-CoV-2: Ensure the medium ventilation rate per hour: 160 l/second/patient.
- For corridor of isolation room: 2.5 l/second/m3.
- For procedure room for nebulization: 60 l/second/patient
- Air Change Rate Per Hour (ACH): 6-12 ACH
5.2.2. Mechanical ventilation
- For an isolation room for people with confirmed or suspected SARS-CoV-2:
+ A negative pressure differential of >2.5 Pa (0.01-inch water gauge)
+ An airflow differential >125-cfm (56 l/s) exhaust versus supply
+ Air Change Rate Per Hour (ACH): 6-12 ACH (equivalent to 40- 80 l/s/patient for a 4x2x3 m3 room), ideally 12 ACH for a new building, 6 ACH for an old building with the recommended negative pressure difference of 2.5 Pa between corridor and patient room (see Appendix 13).
+ Allowable air leakage: 0.046 m2 (0.5 square feet).
+ The air flows from clean to less clean area. The airflow direction can be assessed by measuring the differential pressure between rooms with the differential pressure gauges. If pressure measurement cannot be performed, the airflow direction can be determined by using a smoke generator. Based on the movement of the created smoke to determine the direction of the airflow.
+ An exhaust to the outside, or a HEPA-filter if room air is recirculated.
- For procedure room for nebulization: 6 ACH. Under ideal conditions, the nebulization shall be implemented in a negative pressure room.
6. Responsibilities
- Department of Infection Control is responsible for inspection, surveillance and urging of strict compliance with regulations.
- Medical Supplies and Equipment Department is responsible for training full-time staff managing ventilation system; choosing, installing and maintaining ventilation equipment in conformity with conditions of the medical examination and treatment establishment.
- Examination and treatment unit for people with confirmed or suspected SARS-CoV-2: ensure to abide by regulations of areas under its management.
- The General Planning Department: monitor the implementation, receive, and report to ask for the hospital’s management board to resolve, problems arising during the execution of this regulation.
WASTE TREATMENT
1. Objectives
- Healthcare workers, patients with confirmed or suspected SARS-CoV-2 shall strictly follow the procedures for sorting, isolating, collecting, transporting and treating waste generated from isolation areas.
- Prevent the spread of SARS-CoV-2 from waste to the environment and community.
- Ensure the safety for patients, healthcare workers and community.
2. Principles
- All wastes which must be collected and treated immediately at the generating areas, including screening areas, isolation areas for patients with confirmed or suspected SARS-CoV-2 are considered as infectious wastes, which must be collected in yellow plastic bags and containers with biohazard symbol.
- Ensure no spread of pathogens in the process of collecting, transporting and treating of medical waste from screening areas, isolation areas for people with confirmed or suspected SARS-CoV-2; ensure the safety for healthcare workers and participants in medical waste management.
- When disposing of medical waste, it must be placed into a yellow bag before being transferred to the centralized waste storage in the hospital and noted with “Potential SARS-CoV-2 Waste” warning.
- Healthcare workers and participants in medical waste management and environmental sanitation must be fully equipped with appropriate personal protective equipment while working.
3. Scope of application
3.1. Subjects
- Personnel in charge of collecting, transporting and treating waste generated from people with confirmed or suspected SARS-CoV-2.
- All healthcare workers involved in the care and treatment of people with confirmed or suspected SARS-CoV-2.
- People with confirmed or suspected SARS-CoV-2, patient relatives, visitors.
3.2. Areas
- In all areas having waste generated from people with confirmed or suspected SARS-CoV-2: reception, screening, isolation, testing areas, etc. for people with confirmed or suspected SARS-CoV-2.
- Waste treatment area.
4. Vehicles
- Containers and plastic bags used for collection of infectious medical waste as regulated (in yellow) with symbol of infectious waste are placed in screening areas, isolation rooms, patient rooms and anteroom.
- On injection trolleys or in isolation rooms equipped with sharps containers (yellow, puncture resistant, disposable).
- On transportation vehicles for people with confirmed or suspected with SARS-CoV-2.
- Protective equipment (cap, masks, goggles, clothing, rubber boots/shoes cover) for personnel involved in collection, treatment and management of medical waste.
5. Method of implementation
- Waste which are specimens from people with confirmed or infected SARS-CoV-2 must be safely treated according to the instructions for handling of wastes at high risk of infection before placing into the centralized treatment system.
- All solid waste generated in screening areas, isolation areas and areas related to people with confirmed or suspected SARS-CoV-2 must be collected immediately into infectious waste containers, boxes or bags.
- Infectious waste containers at temporary storage area must be closed tightly, ensure that waste is not dropped or leaked during the collection process to centralized storage areas within the medical facilities at least twice a day.
- Personnel in charge of collecting and transporting waste must wear protective equipment in accordance with regulations.
Figure 27: “Potential SARS-CoV-2 Waste” label
- Waste must be transported to the centralized waste storage in the hospital at least twice a day and when required.
- Before being transported to the centralized waste storage in the hospital, waste must be tightly packed in yellow plastic bags in the isolation room and in other yellow bags after being removed out of the isolation room with the label “Potential SARS-CoV-2 Waste”.
- Once being transferred to the centralized waste storage in the hospital, waste is treated and disposed in a centralized manner like other highly infectious wastes. Never open these waste bags when storage, transportation and treatment are performed.
- Liquid wastes such as faeces, urine generated from isolation rooms or isolation areas need to be collected according to the general medical wastewater collection and treatment system of the hospital. In cases the medical facilities do not have the wastewater treatment system that meet environmental standards, liquid wastes generated from isolation areas must be collected and disinfected with chemicals containing 1.0% of active chlorine before disposing to the environment.
- Respiratory secretions (sputum, saliva, throat fluid, bronchial fluid of patients must be thoroughly treated with solution of 1.0% active chlorine in a 1:1 ratio for at least 10 minutes after it is collected according to regulations in treatment establishment.
- At medical facilities with high-temperature autoclaves, solid waste and specimens generated from the laboratory should be steamed at 121°C for 20 minutes before waste is centralized and treated in accordance with regulations.
- Centralized transportation and treatment: Infectious waste containers must comply with the Joint Circular No. 58/2015/TTLT-BYT-BTNMT dated December 31, 2015 of the Ministry of Health and the Ministry of Natural Resources and Environment stipulating regulations on medical waste management with “Potential SARS-CoV-2 Waste” label, firm container wall, tightly covered lid and wheelchair. Infectious waste must be transported and treated immediately during the day. Time and path for waste transportation should avoid crowds.
- Linens, used clothes of people with infected or suspected with SARS-COV-2, personal protective equipment of healthcare workers and participants in medical waste management and environmental sanitation in screening, monitoring, isolation, care and treatment areas for people with confirmed or suspected SARS-CoV-2 must be collected and treated as infectious waste stated above.
6. Inspection and surveillance
- Department of Infection Control, Nursing Department, Head of Departments and Head Nurses of relevant departments are responsible for training, inspecting, monitoring and urging the strict implementation of procedure for managing waste related to people with confirmed or suspected SARS-CoV-2. Content of monitoring:
+ Vehicles for collection and transportation.
+ Practices of classification, collection, transportation and destruction
+ Amount of waste generated.
- Immediately report to Head of Departments, Head Nurses, the COVID-19 Epidemic Prevention Team and the hospital leaderships in cases of incidents or any problems related to spreading the source of contamination from waste.
Vietnamese
Decision 5188/QĐ-BYT DOC (Word)
Decision 5188/QĐ-BYT PDF (Original)
