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Ministry of Health & Family Welfare Directorate General of Health Services
Guidance document on appropriate management of suspect / confirmed cases of COVID – 19 1. Introduction: Since its first detection in China, Coronavirus Disease 2019 ( COVID – 19 ) has now spread to over 210 countries / territories, with reports of local transmission happening across the world. As per WHO ( as of 7th April, 2020 ), there has been a total of 12, 14, 466 confirmed cases and 67, 767 deaths due to COVID – 19 worldwide.
In India, as on 7th April, 2020, 4421 confirmed cases and 114 deaths reported from 31 States / UTs.
- Purpose of this document A series of measures have been taken by both the Central and State Governments to break the chain of transmission. One among these is to isolate all suspect and confirmed cases of COVID – 19. However, as the number of cases increases, it would be important to appropriately prepare the health systems and use the existing resources judicially. Available data in India suggests that nearly 70 % of cases affected with COVID – 19 either exhibit mild or very mild symptoms. Such cases may not require admission to COVID – 19 blocks / dedicated COVID – 19 hospitals. It is important to put in place mechanisms for triaging and decisions making for identification of the appropriate COVID dedicated facility for providing care to COVID – 19 patients. The purpose of this document is to put in place such SOPs to ensure optimal utilization of available resources and thereby providing appropriate care to all the COVID – 19 patients. This will ensure that available hospital beds capacity is used only for moderate to severe cases of COVID – 19. The SOPs specified hereafter also specify the different types of facilities to be set up for various categories of Covid – 19 cases.
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Guiding principles Al the selected facilities must be dedicated for COVID management. Three types of COVID dedicated facilities are proposed in this document. All 3 types of COVID Dedicated facilities will have separate ear marked areas for suspect and confirmed cases. Suspect and confirmed cases should not be allowed to mix under any circumstances. All suspect cases ( irrespective of severity of their disease ) will be tested for COVID – 19. Further management of these cases will depend on their ( i ) clinical status and ( ii ) result of COVID – 19 testing. All three types of facilities will be linked to the Surveillance team ( IDSP ) All these facilities will follow strict infection prevention and control practices
- Types of COVID Dedicated Facilities: There are three types of COVID Dedicated Facilities – ( 1 ) COVID Care Center ( CCC ): 1. 1. The COVID Care Centers shall offer care only for cases that have been clinically assigned as mild or very mild cases or COVID suspect cases. 1. 2. The COVID Care Centers are makeshift facilities. These may be set up in hostels, hotels, schools, stadiums, lodges etc., both public and private. If need be, existing quarantine facilities could also be converted into COVID Care Centers. Functional hospitals like CHCs, etc, which may be handling regular, non – COVID cases should be designated as COVID Care Centers as a last resort. This is important as essential non COVID Medical services like those for pregnant women, newborns etc, are to be maintained. Wherever a COVID Care Center is designated for admitting both the confirmed and the suspected cases, these facilities must have separate areas for suspected and confirmed cases with preferably separate entry and exit. Suspect and confirmed cases must not be allowed to mix under any circumstances. 1. 4. As far as possible, wherever suspect cases are admitted in the COVID Care Center, preferably individual rooms should be assigned for such cases. 1. 5. Every Dedicated COVID Care Centre must necessarily be mapped to one or more Dedicated COVID Health Centres and at least one Dedicated COVID Hospital for referral purpose ( details
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given below ). 1. 6. Every Dedicated COVID Care Centre must also have a dedicated Basic Life Support Ambulance
( BLSA ) equipped with sufficient oxygen support on 24×7 basis, for ensuring safe transport of a
case to Dedicated higher facilities if the symptoms progress from mild to moderate or severe. 1. 7. The human resource to man these Care Centre facilities may also be drawn from AYUSH
doctors. Training protocols developed by AIIMS is uploaded on MOHFW website. Ministry of AYUSH has also carried out training sessions. The State AYUSH Secretary / Director should be involved in this deployment. State wise details of trained AYUSH doctors has been shared with the States. Their work can be guided by an Allopathic doctor.
( 2 ) Dedicated COVID Health Centre ( DCHC ): 2. 1. The Dedicated COVID Health Centre are hospitals that shall offer care for all cases that have been
clinically assigned as moderate. 2. 2. These should either be a full hospital or a separate block in a hospital with preferably separate
entry exit / zoning. 2. 3. Private hospitals may also be designated as COVID Dedicated Health Centres. 2. 4. Wherever a Dedicated COVID Health Center is designated for admitting both the confirmed and
the suspect cases with moderate symptoms, these hospitals must have separate areas for suspect and confirmed cases. Suspect and confirmed cases must not be allowed to
mix under any circumstances. 2. 5. These hospitals would have beds with assured Oxygen support. 2. 6. Every Dedicated COVID Health Centre must necessarily be mapped to one or more Dedicated
COVID Hospitals. 2. 7. Every DCHC must also have a dedicated Basic Life Support Ambulance ( BLSA ) equipped with
sufficient oxygen support for ensuring safe transport of a case to a Dedicated COVID Hospital if the symptoms progress from moderate to severe.
( 3 ) Dedicated COVID Hospital ( DCH ): 3. 1. The Dedicated COVID Hospitals are hospitals that shall offer comprehensive care primarily for
those who have been clinically assigned as severe. 3. 2. The Dedicated COVID Hospitals should either be a full hospital or a separate block in a hospital
with preferably separate entrylexit.
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- 3. Private hospitals may also be designated as COVID Dedicated Hospitals. 3. 4. These hospitals would have fully equipped ICUS, Ventilators and beds with assured Oxygen support. 3. 5. These hospitals will have separate areas for suspect and confirmed cases. Suspect and confirmed cases should not be allowed to mix under any circumstances. 3. 6. The Dedicated COVID Hospitals would also be referral centers for the Dedicated COVD Health Centers and the COVID Care Centers. All these facilities will follow strict infection prevention and control practices.
- Management of COVID cases
- 1. Assessment of patients: In addition to patients arriving directly through helpline / referral to above categories of COVID dedicated facilities, in field settings during containment operations, the supervisory medical officer to assess for severity of the case detected and refer to appropriate facility. States UTS may identify hospitals with dedicated and separate space and set up Fever Clinics in such hospitals. The Fever Clinics may also be set up in CHCs, in rural areas subject to availability of sufficient space to minimize the risk of cross infections. In urban areas, the civil general hospitals, Urban CHCs and Municipal Hospitals may also be designated as Fever Clinics. These could be set up preferably near the main entrance for triage and referral to appropriate COVID Dedicated Facility. Wherever space allows, a temporary make shift arrangement outside the facility may be arranged for this triaging. The medical officer at the fever clinics could identify suspect cases and refer to COVID Care Centre, Dedicated COVID Health Centre or Dedicated COVID Hospital, depending on the clinical severity.
- 2 Categorization of patients Patients may be categorized into three groups and managed in the respective COVID hospitals – Dedicated COVID Care Centre, dedicated COVID Health Centre and dedicated COVID
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Hospitals. Group 1: Suspect and confirmed cases clinically assigned as mild and very mild Group 2: Suspect and confirmed cases clinically assigned as moderate Group 3: Suspect and confirmed cases clinically assigned as severe
Group 1: Suspect and confirmed cases clinically assigned as mild and very mild ( COVID Care Centres )
Clinical criteria: Cases presenting with fever and / or upper respiratory tract illness ( Influenza Like Illness, ILI ). These patients will be accommodated in COVID Care Centers. The patients would be tested for COVID – 19 and till such time their results are available they will remain in the “ suspect cases ” section of the COVID Care Center preferably in an individual room. Those who test positive, will be moved into the confirmed cases ” section of the COVID Care Center If test results are negative, patient will be given symptomatic treatment and be discharged with advice to follow prescribed medications and preventive health measures as per prescribed protocols. If any patient admitted to the COVID Care Center qualifies the clinical criteria for moderate or severe case, such patient will be shifted to a Dedicated COVID Health Centre or a Dedicated COVID Hospital. Apart from medical care the other essential services like food, sanitation, counseling etc. at the COVID Care Centers will be provided by local administration. Guidelines for quarantine facilities ( available on M HFW website ) may be used for this purpose.
Group 2: Suspect and confirmed cases clinically assigned as moderate ( Dedicated COVID Health Centres )
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Clinical criteria: Pneumonia with no signs of severe disease Respiratory Rate 15 to 30 / minute, SpO2 90 % – 94 % ). Such cases will not be referred to COVID Care Centers but instead will be admitted to Dedicated COVID Health centres. It will be manned by allopathic doctors and cases will be monitored on above mentioned clinical parameters for assessing severity as per treatment protocol ( available on MoHFW website ). They will be kept in ” suspect cases ” section of Dedicated COVID Health Centres, till such time as their results are not available preferably in an individual room. Those testing positive shall be shifted to confirmed cases ” section of Dedicated COVID Health Centre. Any patient, for whom the test results are negative, will be shifted to a non – COVID hospital and will be managed according to clinical assessment. Discharge as per clinical assessment. If any patient admitted to the Dedicated COVID Health Center qualifies the clinical criteria for severe case, such patient will be shifted to a Dedicated COVID Hospital.
Group 3: Suspect and confirmed cases clinically assigned as severe ( Dedicated COVID Hospital )
Clinical criteria: Severe Pneumonia ( with respiratory rate 230 / minute and / or Spo2 < 90 % in room air ) or ARDS or Septic shock Such cases will be directly admitted to a Dedicated coVID Hospital ‘ s ICU till such time as test results are obtained. If test results are positive, such patient will remain in COVID – 19 ICU and receive treatment as per standard treatment protocol. Patients testing negative will be managed with adequate infection prevention and control practices.
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Algorithm for isolation of suspect / confirmed cases of COVID – 19
Suspect cases directly reporting to COVID dedicated facility.
Screening at Fever Clinics
Suspect COVID – 19 Case
Mild and very mild
( Fever / URTI )
Moderate Pneumonia wisho a
Severe ( Respiratory rate > 30 / minute SpO2 < 90 % in room air )
ERR 15 to 30 minute, SpO2 90
Admit to ” Suspect case “
section of COVID CARE CENTER ( hotels / lodges / hostels
Admit to ” Suspect case™
section of DEDICATED COVID HEALTH CENTRE
Admit to DEDICATED COVID
HOSPITAL with ICU facility
Test all for COVID – 19
Test all for COVID – 19
Test all for COVID – 19
Discharge symptomatic management
Manage according to clinical assessment.
Patient to remain in COVID – 19 ICU
Shift to ” Confirmed case ” section of COVID CARE CENTRE Monitor health twice daily Shift to DCHC or CDH if necessary
Shift to non COVID hospital / block and manage according to clinical assessment.
Shift to ” Confirmed case ” section of DEDICATED COVID HEALTH CENTRE
Observing all infection prevention and control practices.
Manage according to clinical assessment
Discharge as per clinical assessment
Discharge as per clinical assessment
Shift to non COVID hospital block when patient becomes stable
Monitor for clinical severity Shift to CDH if necessary