Infection Prevention and Control for ICU during COVID-19 Pandemic: Position Paper of the Indian Society of Critical Care Medicine

Infrastructure^3–8

• The fundamental of ICU design is to ensure safety of both patients and HCWs
• To prevent the spread of infection, “COVID ICU” should preferably be located in a separate dedicated building designated as COVID hospital/wing. In case this is not possible, the COVID ICU should be located away from vulnerable areas such as neonatal ICU (NICU), labor room, dialysis, postoperative surgical unit, etc.
• The COVID ICU should be separated from other ICU patients. At no point, suspected COVID-19 patients should be allowed to mix with confirmed COVID-19 patients.
• The COVID ICU should have a separate entry, exit and accessible through a dedicated lift and/or stairs with round-the-clock security to restrict entry into the ICU.
• At entrance signages for direction and do’s/don’ts for isolation area should be present.
• There should be provision for increase in bed capacity by at least by 20% in case of surge in patients.
• ICUs must have separate donning and doffing area, preferably located in the anteroom at the entrance of ICU. There should be a provision of a washing/bathing area for the HCW to shower after duty before leaving the premises to prevent transmission of infection.
• There can be a provision for resting chambers for the staff post working hours for freshening up to prevent burnout syndrome. However, the HCWs should be allowed to rest only after complete doffing.

Infection Control Facilities^4–7

• Provide appropriate hand washing and hand hygiene facilities in the COVID ICU, preferably with no touch sensors for hand washing.
• There should be provision of shower facility in changing or doffing area for the staff.
• The used linen should be disposed either in a water-soluble bag or in a container filled with 0.5% sodium hypochlorite.
• Provide audio–video communication in ICU patient care areas. This serves as an information channel for the families and communication with their patients, avoiding the necessity of physical visits and reduce cross-transmission risk.
• An ultraviolet (UV) light disinfection chamber should be available in the resting room/change room for disinfection of personal belongings such as keys, cell phones, etc.
• Alternatively, alcohol-based wet wipes should be available for disinfecting personal belongings.

Air Circulation^5,6,8,9

• Air circulation of COVID ICU must be separated from rest of the area of hospital with separate air handling unit (AHU).
• Corridors used for patient’s transport should be well ventilated and periodically disinfected.
• COVID ICU should have sufficient number of airborne infectious isolation rooms (AIIR) for aerosol-generating procedures (AGP) whenever feasible. However, if sufficient single rooms are not available, beds can be arranged with a spatial separation of at least one meter (three feet) from one another.
• AIIR room should have fresh air exchange of 6–12 per hour and is at negative pressure in relation to surroundings (ante-room). There is high-efficiency particulate air (HEPA) filter fixed to the outlet of gases to atmosphere and for recirculation.

Personal Protective Equipment

The PPE recommended for AGPs is comprised of goggles or face-shield, head cover, N95 mask, surgical gloves, coverall/gowns, and shoe cover.

Donning Area

Donning area is a “clean filter” equipped with enough disposable PPE. The other essential items are mirror for donning chairs, surgical scrubs, waste management bin, and hand wash sink with sanitizer.

Donning

There should be a trained observer for review and confirm compliance of the steps of donning process in the donning area.

Steps for Donning (Flowchart 1)

• HCWs should not wear any jewelry in the workplace.
• Scrubs top must be tucked into the scrub pants
• Perform hand wash with soap and water or hand hygiene with alcohol-based hand rub in case hand wash is not possible.
• Collect all articles of PPE and visually inspect them for any damage.
• The gown should be fluid-resistant, non-sterile, and disposable. Make sure the forearms are fully covered and gown is secured on the back while donning the gown.
• Hold the N95 mask in the hands with the straps dangling free. Place the mask securely at the nose and mouth, followed by straps with top one reaching above the ear at the crown of head and lower one below the ears. Mold the nose piece metal to the bridge of nose for a good seal
• The eyes and face are then covered using proper size goggles or a face shield.
• Use surgical gloves made of either latex or nitrile for hands, and pull them till the sleeves of the gown to ensure no skin is exposed. Make sure that your wrists are covered and that no skin is visible.

Doffing

The doffing of PPE is very critical process, as chances of self-contamination are high. The doffing should be done in presence of a trained observer to ensure compliance like donning.

Doffing Area

Doffing area is a “contaminated filter” equipped with waste management bin as per hospital infection control policy, mirror, hand wash sink, and washroom. It is recommended to take shower with soap and water in the hospital premises after doffing.

Steps for Doffing (Flowchart 1)

• Inspect your PPE for any breach. Hand wash with 70% alcohol after each step mentioned below.
• Remove your gloves carefully without touching the outer portion of gloves using the glove-to-glove technique.
• The doffing of gown should be done in front of mirror, with careful untie of strap. The gown is the pulled off the body with carefully rolling the sleeves without self-contamination. The gown is then rolled up like a ball before disposal.
• Remove your eye goggles and/or face shield without having a contact with face.
• N95 mask is to be removed only after exiting isolation area. Do not touch the front surface of the mask. Remove the bottom strap first followed by top strap and discard the mask while holding the straps.
• Clean your hands once again with either soap or water or 70% alcohol.

Team-based Approach for Optimization of Staff Resources⁷

• The key is to create a core COVID-19 team urgently, multiple back up teams of HCWs, and to develop coordination between the individual teams.
• The core team should comprise of doctors, nurses, and various other HCWs who are preferably young (%3C;45 years of age) and without comorbidities. Those who are aged more than 60 years, with multiple comorbidities, pregnant or lactating women, and those who are on immunosuppression are not to be included in the team.
• The team should be led by a senior intensivist who can be actively involved in the patient care, thus building confidence in the other team members.
• The core team should be a mix of experts in airway and other ICU procedures, experienced ICU nurses, respiratory therapists, infectious disease (ID) specialists, and heads of other supporting staff.
• The core team should recruit multiple small teams that would work as back up teams in the event of an HCW falling ill or on an emergency leave.
• The teams should be rotated based on their skills, and there should not be any bias in allocation of duties.
• Sources of additional staff should be prioritized to meet the surge capacity.¹¹ Internal resources mobilization include HCWs from non-COVID units of the hospital, non-clinical positions, medical/nursing interns, etc. External resources include tele ICU support, prehospital services, etc.
• Open channels of communication and regular online huddles with the staff are encouraged. Psychological support and local helplines are to be established.

Training in Infection Control Measures³

• HCWs are highly vulnerable to cross-infection, and uncontrollable hospital outbreak could cripple the hospital service in a very short time.
• All of the ICU staff must follow procedures of infection prevention and control (IPC) completely. An infection control coordinator must monitor the compliance of all policies and procedures of IPC.
• Buddy system is a recommended tool that can be tried to ensure good compliance of IPC measures.¹²
• Buddy system: A team of two or more staff is formed with shared responsibilities of each other safety and well-being. Buddy system approach is useful for various critical measures of IPC like (i) Safe donning and doffing of PPEs, (ii) compliance of hand hygiene, and (iii) observation and reporting of any breach of PPEs.^11,12

Surge Teams and Tiered Strategies^13,14

• It is difficult for any hospital to increase the staff capacity to match the surge in cases.
• Due to surge of cases, normal division of tasks between nursing and medical teams may not be possible. Identification of critical tasks and division of them between the various staff is advised.
• In case of surge, the ICU physician and nurses instead of direct patient care may take a supervisory role, with HCWs from outside ICU may be actually deployed to provide direct patient care.
• Tiered staffing strategy as recommended by Society of Critical Care Medicine (SCCM) could be adopted with a single ICU physician overseeing 3–4 teams led by non-ICU physicians.

Staff Credentialing and Wellness¹⁴

• The credentialing process should be expedited and should be readily reckonable.
• The hospital should ensure that all the staff are medically insured.
• The staff should undergo periodical temperature checks and screening for any symptoms of COVID-19.
• In case of a member of the team developing symptoms of COVID-19, they should be prioritized for the testing.

Housing for the Staff and Family Needs¹⁴

• The staff working in COVID ICU should follow the principles of infection control and social distancing in the housing quarters.
• The hospital should address the family needs of the staff who are staying away from their families for long time. This may include HCWs child support, preferential treatment to the families of the staff, etc.

Shift Hours and Payment to Staff

• In view of vulnerability of the ICU staff to high viral load, the shift hours should be short and preferably not to exceed 6–8 hours.¹⁴
• Timely payment of the salaries may boost the confidence of working staff. Reasonable monetary incentives can be considered wherever feasible and applicable.
• As far as possible, the staff on ICU duty should be staying in the premises or nearby (to prevent infection) and easy availability in case of sudden surge.

Hospital Disinfectants^9,16

• As far as possible, single-use or disposable equipment must be used. The nondisposable equipment can be disinfected with either 70% ethyl alcohol or quaternary ammonium compounds
• Sodium hypochlorite at 0.5–1% for surface disinfection (Table 1)

Surface Cleaning

Surfaces can be divided into two groups depending on the degree of use to either high-touch surfaces (HTS) or low-touch surfaces (LTS). Wear gloves when handling and transporting used patient care equipment.⁹

Cleaning and Disinfection of Medical Equipment

Medical equipment must also be disinfected before removing equipment from patient’s room.

Noncritical Medical Equipment^5,9,16

The examples of noncritical equipment include stethoscopes, blood pressure cuffs, etc. They need low to intermediate level of disinfection after cleaning for removal of any organic matter (Table 2).

Terminal Cleaning after Discharge of Patients^5,6,15,16

• Terminal cleaning is complete environmental decontamination of the patient care area after discharge.
• Terminal cleaning includes cleaning for removal of any organic or nonorganic matter followed by disinfectant process
• Housekeeping staff should wear full PPE—surgical mask or N95 mask, protective eyewear, coverall/gown, and gloves—before entering patient-care area
• Clean all surfaces of bed and mattress with 1% sodium hypochlorite.
• Wash the floor with wet mop followed by disinfection with 1% sodium hypochlorite.
• In case of accidental exposure, disinfection should be done according to area exposed (Table 3).

Biomedical Waste Management^17,18

• Separate color-coded bins/bags/containers in ICU should be kept for proper segregation of waste based on hospital infection control policy as per Biomedical Waste Management (BMWM) Rules, 2016, and Common Bio-medical Control Board (CPCB) guidelines.
• The bags (using two bags) should be covered in double layers for collection of waste in ICU to provide adequate strength and to prevent any leaks.
• The waste collected from COVID area should be clearly marked and stored separately from other BMW, prior to handing over to Biomedical Waste Treatment and Disposal Facility (CBWTF). In case this is not possible, BMW can be handed over directly to CBWTF staff.
• For easy identification of BMW from COVID area, they can be labeled “COVID-19 Waste”. This labeling will be helpful for housekeeping staff and CBWTFs staff to identify the waste easily prior to appropriate disposal.
• General waste not having contamination should be disposed as solid waste as per Solid Waste Management (SWM) Rules 2016.
• Maintain separate record of waste generated from COVID-19 isolation wards

Dead Body Management^19,20

• The staff responsible for handling dead bodies should be trained by infection control nurse in IPC practices and safety. This include the staff in the isolation ICU, mortuary, ambulance, or those working in the crematorium/burial ground.
• All personnel responsible for handling dead body should take standard precautions, including hand hygiene before and after handling, and use appropriate PPE, including a fluid-resistant apron and surgical gloves.
• Facial protection using a face shield or googles must be done in case of risk of splashes of either body fluids or secretions.
• Remove all lines, catheters, or other tubes before packing the body.
• Any body fluids leaking from orifices must be properly contained before packing.
• The body handling should be kept as minimum as possible and by restricted trained personnel only.
• The dead body must be placed in a leakproof plastic body bag, preferably double layered; 1% hypochlorite can be used to decontaminate exterior of the body bag.
• It is important to maintain appropriate temperature at the mortuary, as heat and humidity will cause body decomposition.

Safety Precautions

• All specimens collected from a suspected or confirmed COVID-19 patient are potentially infectious and must be handled appropriately.
• The staff responsible for collection, handling, and processing specimens must be trained by infection control nurse for appropriate specimen collection, storage, packaging, and transport. Appropriate PPE is mandatory for sample collection.
• The PPE includes gown, head cap, face shield/goggles, N95 respirator, gloves, and shoe covers.²¹
• The laboratory staff responsible for handling such specimen should be specifically trained in technical and biosafety measures.
• All molecular diagnostic specimen must be handled only in laboratory with biosafety level (BSL)-2 or equivalent facilities. Any attempt to viral isolation using culture only to be done in a laboratory equipped with BSL-3 or higher as per national guidelines on laboratory biosafety.²²

Requirement for Sample Collection

• Sterile polyester tipped plastic stalk swabs
• Viral transport medium (VTM)
• Tongue depressor
• Plastic zip lock bag
• Cool box with frozen gel pads (−20°C)
• Cryo-labels
• Sealing tape
• PPE equipment
• Alcohol based hand rub
• Biohazard discard bag

Specimen collection should use only synthetic fiber swabs made on plastic or wire shafts. Calcium alginate swabs or wooden shafts should not be used, as it may inactivate some viruses or inhibit polymerase chain reaction (PCR) testing by reducing viral yield.

Specimen Type^23,24

• The critical steps in the diagnosis of SARS-CoV-2 using reverse transcriptase (RT)-PCR is collecting the correct specimen from the patient at the right time.
• The viral yield is maximal during first few days after onset of illness onset, and detection becomes less likely after 10 days from symptoms onset.²³ The RT-PCR is useful for SARS-CoV-2 detection in the first week of illness for nasopharyngeal specimen and at weeks 2–3 for stool.²⁴
• Respiratory specimen must be collected from both upper and lower respiratory tract wherever feasible for higher detection (Table 4).

Collection of Specimen

The proper collection of specimens is a crucial step in the laboratory diagnosis of SARS-CoV-2. An inadequate specimen may lead to false-negative test results. Samples must be collected at the earliest once the patient is suspected as infected, regardless of the time since onset of symptoms. The specimen collection guidelines can follow recommendations by World Health Organization (WHO)²⁵ and Centre for Disease Control and Prevention (CDC).²⁶

• The sample vial should be properly labelled and patient under investigation (PUI) form should be filled before collection.
• Patient is seated or lying in a comfortable position on the bed.
• The procedure must be explained clearly to the patient to ensure cooperation.
• Staff for sample collection must be wearing recommended PPE.
• Specimen after collection should be transported immediately to the laboratory in the vial containing viral transport media (VTM).

Sample Handling at Collection Site

• Vial/container should be clearly labeled with unique specimen ID.
• VTM containing samples should be wrapped into triple packaging and kept into a cool box immediately after collection (Fig. 2).
• Specimen should be immediately transported to laboratory after collection.
• If the specimens cannot be sent to the laboratory for processing, store specimens at 2–8°C for up to 72 hours after collection. They should be stored at or below −70°C in ultra-low freezer if further delay is anticipated (Table 5).
• Avoid repeated freezing and thawing of the specimen.

Management of Exposed Staff^28–30

• The HCWs who are exposed to COVID-19 should be managed as per the risk assessment (Table 6).
• The assessment of exposure and degree of risk involved in terms of exposure and its translation to infection is critical for appropriate management.
• The exposure risk can be assessed through systematic tools available from WHO, CDC, or Ministry of Health and Family Welfare (MOHFW).
• The purpose of risk assessment is to identify the degree of exposure and can be stratified into high and low risk (Table 6).
• Low-risk exposure continues to work with self-monitoring of symptoms.

Staff Quarantine High-risk Exposure

• Staff are immediately sent to quarantine for 7 days with the first day being the day of exposure.
• Staff should be trained for self-monitoring of symptoms consistent with COVID-19.
• As per ICMR guidance, all asymptomatic high-risk exposure should be tested after one week and immediately if symptomatic.³¹

Management of Symptomatic Exposure

• All symptomatic HCWs should immediately stop reporting to work and inform to head of the department (HOD).
• They can report to hospital COVID Nodal officer/HOD for clinical assessment, testing, and further management as per MOHFW guidelines.
• Those who tested negative for SARS-CoV-2 RT-PCR can be treated for their illness in non-COVID area as per the clinical diagnosis.
• Their return to work will be decided as per the clinical diagnosis and fit to work certificate from the treating doctor.

Return to Work Criteria of COVID-19 Healthcare Workers

The return to work for an HCW who has recovered from COVID-19 is based on the hospital policy and national guidelines. There are two approaches that can be followed either based on symptoms or based on testing (Table 7).

The HCWs who are returning to work must report to HOD of ICU and infection control nurse (ICN) and advised on

• continue to wear appropriate PPE as per risk at workplace at all times.
• reinforcement of IPC practices, and
• self-monitor for symptoms consistent with COVID-19 and, seek immediate re-evaluation in case symptoms recur or worsen.