federal government of somalia ministry of health & … · 2020. 5. 1. · sop case management...

SoP Case management COVID-19 v.1 1

DOWLADDA FEDERAALKA SOOMAALIYA

WASAARADDA CAAFIMAADKA IYO DARYEELKA BULSHADA

FEDERAL GOVERNMENT OF SOMALIA

MINISTRY OF HEALTH & HUMAN SERVICES

NATIONAL STANDARD OPERATING

PROCEDURES (SOP): CASE MANAGEMENT

COVID-19


Standard Operating Procedures (SoP): Case Management COVID-19 This Standard Operating Procedure (SOP) is intended for clinical management of COVID-19 suspected, confirmed cases identification, isolation and management at point of entry, health care facility and community level. The public health objectives at all stages of the preparedness and response plan are to:

• Prevent outbreaks, delay spread, slow and stop transmission.

• Provide optimized care for all patients, especially the seriously ill.

• Minimize the impact of the pandemic on health systems, social services, and economic

activity.

Case definition: Suspected case:

• A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory

disease (e.g., cough, shortness of breath),

• AND with no other aetiology that fully explains the clinical presentation

• AND a history of travel to or residence in a country/area or territory reporting local

transmission of COVID-19 disease during the 14 days prior to symptom onset. OR

• A patient with any acute respiratory illness

• AND having been in contact with a suspected or confirmed COVID-19 case in the last 14 days

prior to onset of symptoms; OR

• A patient with severe acute respiratory infection (fever and at least one sign/symptom of

respiratory disease (e.g., cough, shortness breath)

• AND requiring hospitalization

• AND with no other aetiology that fully explains the clinical presentation.

Confirmed case: A person with laboratory confirmation (PCR) of COVID-19 infection, irrespective of clinical

signs and symptoms.

Contact: A contact is a person who experienced any one of the following exposures during the 2 days before and the 14 days after the onset of symptoms of a suspected or confirmed case:

• Face-to-face contact with a suspected or confirmed case within 1 meter and for more than 15

minutes;

• Direct physical contact with a suspected or confirmed case;

• Direct care for a patient with suspected or confirmed COVID-19 disease without using proper

personal protective equipment; OR

• Other situations as indicated by local risk assessments.

For Community Health Workers: A person with acute airway illness with hotness of body AND at least with cough/shortness of breath AND a history of travel to or living in a country/area with COVID-19 disease during the 14 days before illness began OR had contact with a person with similar illness.


Points of Entry (PoE) HEALTH FACILITIES (OPD/HOSPITALS)

ISOLATION UNIT

Home

quarantine

Health

education

Hygiene Kit

Home

quarantine

Health

education

Hygiene Kit

SCREENING & TRIAGE TRIAGE

Non suspects

Non suspects

Suspects

Suspects

Health Education

Health Education

Symptomatic

Symptomatic

Asymptomatic/Mild

symptoms

Asymptomatic/ Mild symptoms

Isolation (TEST)

Confirmed Suspected

Moderate Severe

ICU Ward

Isolation

Moderate Critical

Ward

Isolation: Separation of ill or infected persons from others, so as to prevent the spread of infection or contamination

Quarantine: Restriction of activities or separation of persons who are not ill, but might have been exposed to an infectious agent/person or disease

Self-quarantine: Restriction of activities or separation of persons who are not ill, but might have been exposed to an infectious agent or disease; at home

COMMUNITY

Community sensitization

Risk Communication

Community self-reporting

Contact tracing

Screening points

Risk Communication

IEC materials

Isolation room/area at PoE

Non suspects

Suspects

Health Education

Quarantine Home

quarantine

Isolation

Suspects

HEALTH FACILITIES (OPD/HOSPITALS)

History of travel in last 14 days and fever

CHW

CHW

Mild

Home

quarantine

Health

education

Hygiene Kit

CHW

Mild

Home

quarantine

Health

education

Hygiene Kit

CHW CHW


KEY CLINICAL AND IPCs ACTIVITES

A. Points of Entry:

a. Designated Health staff for screening

i. Wear masks

ii. Frequent handwashing with soap and water for at least 20 seconds

b. Separate room is strongly recommended for suspects c. Designated ambulance referrals

d. Record names, residence and contact numbers of all travelers

B. Health facilities (OPD/Health Centres/Hospitals) and ISOLATION UNIT (For details clinical management please refer to Annex 1, Annex 2): 1. Screening and TRIAGE area:

a. Self-reported guidance:

i. Fever, cough, shortness of breath

ii. Any other patients

b. Non-suspect (EXIT) then provide routine care for patient’s health need

c. Suspect cases with fever and/or cough only (EXIT to home quarantine)

d. Suspect cases with shortness of breath (EXIT to isolation treatment area)

i. For Health Centers, move suspected cases using the COVID-19

specific emergency referral pathway to the nearest isolation unit

ii. For Tertiary and referral facilities move suspected patients to the

nearest isolation unit

2. Isolation area:

a. Masks for all suspects with respiratory symptoms

b. Designated staff (in isolation area but not providing direct assistance)

should wear medical mask and gloves

c. Separate waiting area and ensure drinking water is available

d. Maintain at least 1-meter distance between suspected patients and other

patients

e. Health education and hygiene kit (handwashing station)

f. Strict IPC system

g. Laboratory sampling

h. Segregate symptomatic suspects from confirmed cases

i. Symptomatic management (please refer WHO guidelines on clinical

management)

j. Only use a particulate respirator (N95/ FFP2 or equivalent), when

performing aerosol-generating procedures, such as tracheal intubation,

non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation,

manual ventilation before intubation, and bronchoscopy.

C. Quarantine area:

a. Masks and gloves for medical staffs during daily follow up

b. Mask for patients and staff in the ambulance during referral

c. Separate area for suspects and staffs (Living quarter, toilets, showers etc.)


d. Adequate food assistance including specialized nutritious food, water, hygiene

provision

e. Adequate food, water, hygiene provision

f. Frequent handwashing with soap and water for at least 20 seconds

g. Practice respiratory hygiene

h. Refrain from touching the eyes, nose and mouth

i. Cleaning personnel should wear disposable gloves and mask when cleaning

For all health facilities and PoEs, data of patient management and supplies provided should be well documented

D. Home quarantine:

a. Symptomatic

i. Symptomatic Use a medical mask and seek medical care if fever (Temperature above 38 degrees Celsius), cough, and difficulty breathing/

shortness of breathing

- Frequent handwashing with soap and water for at least 20 seconds

- Keep a distance of at least 1 meter from other people

- Improve airflow in their living space

- Caregivers or those sharing living space:

a. Designated caregiver if possible

b. Frequent hand handwashing with soap and water for at least

20 seconds

c. Keep at least 1-meter distance if possible

ii. Wear a medical mask when in the same room as the affected person Dispose

of any material contaminated with respiratory secretions (disposable tissues)

immediately after use and then perform handwashing with soap and water

for at least 20 seconds

ii. Report daily on fever, shortness of breath or any other symptoms to

assigned health worker.

b. Asymptomatic:

i. Avoid groups of people and enclosed, crowded spaces

ii. Maintain distance of at least 1 meter from any person with respiratory

symptoms (e.g. coughing, sneezing);

iii. Frequent handwashing with soap and water for at least 20 seconds

iv. Respiratory etiquette (cover nose and mouth if coughing or sneezing)

v. Refrain from touching mouth, nose and eyes

Reference:

1. https://www.who.int/docs/default-source/coronaviruse/20200229-covid-19-

quarantine.pdf?sfvrsn=9aef4b3c_1&download=true

2. https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-

coronavirus-(2019-ncov)

3. https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-

eng.pdf

https://www.who.int/docs/default-source/coronaviruse/20200229-covid-19-quarantine.pdf?sfvrsn=9aef4b3c_1&download=truehttps://www.who.int/docs/default-source/coronaviruse/20200229-covid-19-quarantine.pdf?sfvrsn=9aef4b3c_1&download=truehttps://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdfhttps://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf


4. https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-

home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-%282019-ncov%29-

outbreak

Annex 1: Clinical management in Outpatient Departments or Health Centres

Screening and TRIAGE area:

a. Self-reported guidance:

a. Fever, cough, shortness of breath

b. Any other patients

b. Non-suspect (EXIT) then provide routine care for patient’s health need

c. Suspect cases with fever and/or cough only (EXIT to home quarantine)

d. Symptomatic & Mild cases:

- Signs and symptoms:

• Cough and sore throat,

• Low grade fever


Annex 2: Clinical management in Isolation set-up (COVID-19 Confirmed cases): High risk groups for Complications:

o Age > 60 years

o Smoker

o Cardiovascular disease

o Diabetes

o Hypertension

o Immune deficiencies

o Chronic kidney disease, Chronic

Respiratory disease, Chronic Liver

Disease

o Malnutrition

o Ongoing treatment of cancer patients

BASELINE INVESTIGATIONS FOR CONFIRMED PATIENTS in Isolation unit:

a. LABORATORY TESTS

• Every patient admitted to the ward/ICU should have the

following baseline investigations: CBC, CRP, ESR, Serum Glucose,

Serum electrolytes, Liver function tests, Urea and Creatinine,

Coagulation profile, LDH, D-Dimer and Troponin

b. CHEST IMAGING: Chest X-ray (Mandatory) and CT scan of Chest (if available)

c. ECG (for moderate and severe cases under treatment)

d. VIROLOGICAL TESTS

• Viral RNA can be detected in nasopharyngeal swabs, sputum, lower

respiratory tract secretions using RT-PCR or NGS.

• Recommend collecting lower respiratory tract samples (sputum or

air tract extraction) to increase the sensitivity

1- Symptomatic & Mild cases:


- Cough and sore throat,

- Low grade fever


- Shortness of breathing with no signs of sepsis or ARDS

- Respiratory rate of 20-30/min

- Heart rate 100-120/min

- O2 Saturation on room air 90-94%

- Management:

• Monitoring of pulse, respiratory rate and saturation (Every 6 hours or as

clinically indicated)

• Observe for evidence of deterioration.

• Monitor High risk patients frequently (e.g.: Age more than 50 yrs./

diabetes/ cardiovascular diseases/ other comorbidities)

• To be managed in the designated ward/area for COVID 19 patients

• Therapies:

o Paracetamol IV 500mg /6 hrs.

o Augmentin 1g BID for 7-10 days

o Azithromycin 1g first day then 500 mg per day for 3 days

o Oseltamivir 150 mg every 12 hrs for 5 days

o Ascorbic acid 500 mg BID

o Cyanocobalamin IV once daily

3- Symptomatic and Severe cases:


- Pneumonia with ARDS

- Sepsis/Septic Shock and multi-organ failure

- Cough, sore throat

- Fever ≥38°C

- Myalgia

- Shortness of breathing with signs of sepsis and/or ARDS

- Respiratory rate of >30/min

- Heart rate >120/min

- O2 saturation on room air


*Management for patients with severe pneumonia in sepsis and or ARDS with consultation of a

senior consultant

• Intravenous Fluids (Normal saline or Ringer lactate) (patients with

circulatory shock (as evidenced by hypotension, oliguria, cold

peripheries) with caution

• Consider insertion of arterial catheter and central venous catheter early

on those who present with circulatory shock.

• Enteral nutrition via nasogastric tube for feeding

• Hydrocortisone 100 mg vial TDS or Methylprednisolone 1mg/kg IV OD

for 5days (with caution)

• Aminophylline 200 mg over 100 glucose 5 % intravenous every BID (with

precaution for arrhythmia)

• Saline 3 % nebulizer TDS

• Furosemide 20 mg every

• Omeprazole IV 40 mg OD

**Management of ARDS: Similar to the management of severe pneumonia + Ventilator support

ARDS diagnostic criteria:

1) Onset within 1 week of signs of the illness

2) Bilateral opacities consistent with pulmonary edema must be present and may be

detected on CT or chest radiograph 3. P/F (PaO2/ FiO2) ratio

3) P/F (PaO2/ FiO2) ratio


e. Permissive hypercapnia to maintain pH > 7.25

• Adequate sedation and muscle paralysis (< 48 hours) are advised for those

who are on escalating supports from mechanical ventilator.

• Humidification should be essentially applied, and closed suction devices should

be used to prevent frequent ventilator disconnections (avoid de-recruitment of

the lung as well as aerosolization).

• Bacterial and viral filters should be applied during mechanical ventilation.

• Nebulization should be used only when essential.

• Restrictive fluid strategy; patients should be assessed for fluid responsiveness

employing multiple parameters and intravenous fluids should be limited unless

there is circulatory shock.

• Prone ventilation; early prone ventilation for 20 hours or more should be

considered for those who are deteriorating with PF < 150 (severe ARDS).

However, it is crucial to exclude other causes of sudden hypoxemia (e.g.

pneumothorax, lung collapse) before attempting prone ventilation.

• Percutaneous dilated tracheostomy; would be helpful to minimize the need for

sedatives and early weaning. However, too early tracheostomy or transfer of

patient to theatre for tracheostomy and bronchoscopy during percutaneous

procedures may expose others unnecessarily.

• Early mobilization; those who are mechanically ventilated for more than 24

hours should be carefully assessed and started on chest and limb physiotherapy

in order to prevent ICU acquired weakness.

• Weaning; progress should be assessed using regular ABGs and CXR to wean

ventilator supports and liberate patients from the mechanical ventilation. It

may be appropriate to wean patients and extubate early to NIV or high flow

nasal oxygen in order to reduce the complications of prolonged ventilation.

• Communication; do not use personal mobile phones during duty hours.

Availability of a dedicated smart phone and intercom facilities in cohort or

triage ICU is important to improve communication and to prevent frequent

staff movements.

☐ Management of Septic shock

• In addition to sepsis management in severe pneumonia

• Give noradrenaline as the first line vasopressor (patients with circulatory shock

refractory to fluid resuscitation) to achieve MAP ≥ 65 mmHg; Use vasopressin or

epinephrine if noradrenaline is not available. If all the above are not available

use Dopamine.

• If required and advised by senior Consultant give Fresh Whole Blood.

I. ICU admission criteria for COVID-19:

a. Acute and potentially reversible organ dysfunction poorly responding to initial

resuscitation

b. Severe respiratory failure or intubated (SpO2 /FiO2 ratio < 200)

c. Refractory circulatory shock (SBP < 90 mmHg, Lactate > 4)

d. More than single organ failure


II. Discharge criteria from ISOLATION center:

a. When patient is clinically well

b. Free from COVID-19 symptoms

c. Two (2) negative PCR more than 24 hrs apart (preference sputum sample)

d. On discharge patients should follow strict home isolation for minimum of 3 weeks,

as preliminary evidence suggest viral shedding may be prolonged

III. Dead body management of COVID19:

The isolation center authority is responsible for preparing, packing of COVID19 dead bodies

and handover to the families.

- Train 04 staff members in consultation with NIAG on

appropriate preparation and packing (Body bag, 400 micron)

of the dead body

- Organize ambulance for safe transfer of the dead body

- Hand over the dead body to the relatives

Summary of Therapies for Confirmed COVID-19 cases:

Category Management/Therapy

Asymptomatic Home isolation and close monitoring

Mild symptoms

(no high-risk group)

- Paracetamol oral tabs 1g BID

- Ascorbic acid 500mg BID

- Oral B complex

Mild symptoms

(High risk group)

- Paracetamol oral tabs 1g BID

- Ascorbic acid PO 500mg BID

- Oral B complex

- Monitor frequently

Moderate

symptoms

- Paracetamol IV 500mg /6 hrs.

- Augmentin 1g BID for 7-10 days

- Azithromycin tab 1g first day then 500 mg per day for 3 days

- Oseltamivir tab 150 mg BID for 5 days

- Ascorbic acid 500 mg BID

- Monitor Vital signs and SpO2 (Every 6 hours)

Severe or Critical ill

- Paracetamol 500 mg IV QID

- Levofloxacin 500 mg IV BID or

- Meropenem 1g IV TDS (for ICU only)

- Ascorbic acid 500 mg oral BID

- Oseltamivir 150 mg QID

- Cyanocobalamin IV OD

- Management of sepsis and septic shock accordingly


List of equipment and drugs: Infection control

B. Monitoring devices C. Organ support devices

D. Human Resource

1. PPE; N95 masks, surgical masks, overalls, wisers, goggles 2. Parasafe (high level disinfectants)

3. 70% alcohol and TCL (low level disinfectants)

4. Hand wash stations

5. Hand wash solutions

6. Hand rubs

1. Multipara monitors

2. Pulse oxymeters

3. Thermometers (infra-red)

4. Uribags

5. ABG analyser

6. Glucometers

7. Portable X-ray

1.ICU ventilators (1 per bed)

2. Portable ventilators (1 per 5 beds)

3. HFNC machines with accessories

4. Infusion pumps

5. CRRT machines

7. Syringe pumps

8. Pneumatic compression devices

9. Feeding pumps (NG)

1. Doctors

2. Nurses

3. Anesthesiologists

4. Lab Technician

5. Public Health

6. Cleaners

7. Cooks

8. Laundry staff

9. Logistics

10. Security

11. Morgue

E. Drugs F. Consumables 1. Fentanyl vials 2. Morphine vials

3. Propofol 1%

4. Midazolam

5. Rocuronium

6. Suxamethonium

7. Atracurium

8. Vacuronium

9. Glycopyrolate

10. Adrenalin vials

11. Noradrenalin vials

12. Atropine vials

13. Dobutamin vials

14. Vasopressin vials

15. Ephedrine vials

16. Antibiotics (Azithromycin 500mg, Clarithmycin 500Mg & Augmentin 1gr)

17)Cyanocobalamin IV

OD

18) Paracetamol 500

mg IV QID

20. Insulin (Actrapid)

21. Amiodaron IV

22. Amiodaron oral

23. Thiamine vials

24. Ranitidine vials

25. Enoxaparin

26. Haparin vials

27. Haloperidol

28. KCL (pottacium chloride)

29. MgSO4

30. Crystalloids (saline, RL, dextrose, 50%)

31. Lignocain 2%

32. Nebulizer solutions (salbutamol) 32.Levofloxacin 500 mg IV BID 33 Meropenem 1g IV

TDS

34 Ascorbic acid

500mg oral BID

35)Oseltamivir 150mg

QID

1. Endotracheal tubes (sizes 7 -8.5)

2. HMEs

3. Breathing circuits- disposable

4. Bacterial and viral filers for ventilator

5. Closed suction devices for ventilator

6. Suction apparatus with Yanker handle

7. Nasogastric tubes (12-16 FG)

8. Urinary catheters (12-18 FG)

9. Urobags

10. Syringes (1-50 cc)

11. Cannula (14-22 G) 12. Central venous catheters (15-20 cm)

13. Tri-lumen vascath (15- 20 cm)

14. CRRT solutions (Duosol K-2)

15. CRRT kits (machine specific)

Case definition:KEY CLINICAL AND IPCs ACTIVITESA. Points of Entry:a. Designated Health staff for screeningi. Wear masksii. Frequent handwashing with soap and water for at least 20 secondsb. Separate room is strongly recommended for suspectsB. Health facilities (OPD/Health Centres/Hospitals) and ISOLATION UNIT (For details clinical management please refer to Annex 1, Annex 2):

federal government of somalia ministry of health & … · 2020. 5. 1. · sop case management...

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