IAP Guideline on Practicing Safely During COVID-19 Era: Clinics and Small Establishments

Justification:The unprecedented COVID-19 pandemic has had a formidable impact on Indian health care. With no sight of its end as yet, various establishments including the smaller clinics and nursing homes are restarting full operations. Hence, there is the need for recommendations to allow safe practice ensuring the safety of both the heath care worker (HCW) and patients. Process: Indian Academy of Pediatrics organized an online meeting of subject experts on 27 July, 2020. A committee was formed comprising of pediatricians, pediatric and neonatal intensivists, and hospital administrators. The committee held deliberations (online and via emails) and a final consensus was reached by November, 2020. Objectives: To develop recommendations to provide a safe and practical healthcare facility at clinics and small establishments during COVID times. Recommendations: The key recommendation to practise safely in this setting are enumerated. Firstly, organizing the out-patient department (OPD). Secondly, appropriate personal protective equipment (PPE) to provide protection to the individual. Thirdly, decontamination/disinfection of various common surfaces and equipment to prevent transmission of infection from fomites. Next, maintaining the heating ventilation and air conditioning (HVAC) to provide a stress-free, comfortable, and safe environment for patients and HCWs. Finally, steps to effectively manage COVID-19 exposures in a non-COVID-19 facility. All these measures will ensure safe practice during these unprecedent times in clinics and smaller establishments.

## R r r r r e e e e e c c c c c o o o o o m m m m m m m m m m e e e e e n n n n n d d d d d a a a a a t t t t t i i i i i o o o o o n n n n n s s s s s
T he healthcare industry not only bears the brunt of the coronavirus disease (COVID-19) epidemic, but has also to mitigate its spread too. In this regard, putting strict practices and processes in place that are suitable to the local needs and resources will be paramount in fighting this disease effectively.
The Indian Academy of Paediatrics (IAP) has therefore come out with the following guidelines on practicing safely in clinics and small establishments during these unprecedented times.

## Objectives
To develop recommendations to provide a safe and practical health care facility at clinics and small establishments during COVID times, and to ensure safety of the healthcare workers (HCW), and patients at clinics and small establishments.

## Process
The Indian Academy of Pediatrics organized an online meeting of subject experts on 27 July, 2020. A committee was formed comprising of pediatricians, pediatric and neonatal intensivists, and hospital administrators. The committee held various deliberations (online and via emails) and a final consensus was reached by November, 2020.

## Recommendations
The guidelines are applicable for clinics, polyclinics, and level 1 hospitals.
A clinic is defined as a clinical establishment providing examination, consultation, and prescription to outpatients, including dispensing medicines by a single doctor, general practitioner, specialist, or a super-specialist doctor. A polyclinic is similar but managed by more than one doctor, VOLUME 58 __ APRIL 15, 2021 INDIAN ACADEMY OF PEDIATRICS PRACTISING SAFELY DURING COVID-19 general practitioner, specialist, or a super-specialist doctor.A Level 1 (A) hospital is a general medical service with an indoor admission facility, provided by recognized allopathic medical graduate(s) and may also include general dentistry services offered by recognized BDS graduates. Example: Primary Health Care Centre (PHC), government and private hospitals, and nursing homes run by MBBS doctors. A Level 1 (B) hospital shall include all the general medical services provided at level 1(A) and indoor and OPD specialist medical services provided by doctors from one or more basic specialties, namely general medicine, general surgery, pediatrics, obstetrics and gynecology, and dentistry.The guideline will be discussed under these broad subheadings

## Patient
Segregation -It is prudent to cohort children who are ill from the well-baby visits. Many clinics are operated only by the practicing doctor. However, it is recommended to have a helper who will assist in triaging, maintaining decorum, and educating patients. Preferably an initial screening should be followed by separation of those suspected of COVID-19 from others. These cases should not spend time in the waiting area and should be seen immediately. A separate entry, consultation place & exit, if feasible, will help.As not all clinics have the facilities mentioned above, alternate precautions should be followed:
- Telephonic triaging and schedule appointments for all suspect cases after routine OPD- Exclusive days should be allotted for 'Well baby' & Immunization checks once or twice a week. This may even boost parents' morale who otherwise would be scared to come to clinics for vaccinations.. Patient Education and Awareness -All patients should follow respiratory hygiene and cough etiquette. Patients should be provided with tissues, contactless bins, contactless sanitizers, and wash areas. Display these instructions in prominent locations. Patient education is also the physician's responsibility, hence putting educative posters, multimedia information at strategic points is useful.7. One Attendant and Personal Protection -Allow only one parent or guardian with the child.Everybody, including children above two years, should wear a mask.
8. Well Ventilated -Follow the ventilation guidelines provided in this document. [bib_ref] Comparative accuracy testing of non-contact infrared thermometers and temporal artery thermometers in..., Khan [/bib_ref]. Avoid Fomites -Remove toys, magazines, and any items that are likely to be shared between patients in the waiting area or consultation chambers.10. Novel Techniques -Innovative methods have been tried by various doctors and can be utilized.
- Using transparent physical barriers between the patient and doctors can help in decreasing direct exposure to droplets.
- Virtual detailed video interaction followed by a rapid, focused examination of the patient in another chamber minimizes the patient contact time.
- Non-Contact Thermal scanners-These are convenient non-contact devices ideally suited for mass screening in a pandemic and have wide acceptability. However, they lack robust evidence. A recent systematic review VOLUME 58 __ APRIL 15, 2021
[formula] INDIAN ACADEMY OF PEDIATRICS PRACTISING SAFELY DURING COVID-19 [/formula]
showed reasonable diagnostic accuracy in fever detection but may vary with patient characteristics, setting, index test, and the reference standard used. These have an excellent negative predictive value. [bib_ref] Comparative accuracy testing of non-contact infrared thermometers and temporal artery thermometers in..., Khan [/bib_ref] However, there are more recent studies doubting its accuracy during screening in a pandemic.Hence, no specific recommendations are available for or against the use of these devices.

## Personal protective equipment [11]
PPE, along with other measures like engineering and administrative protocols, reduces the exposure of HCW to infectious agents, including the SARV-CoV2 virus. HCW has 11-fold higher chances of getting infected with the SARS-CoV2 virus than the general population. The use of PPE can reduce that risk by 60-80% when exposed to COVID-19 suspected or proven cases. Various components of PPE and its benefits are given in [fig_ref] Table I: Decontamination and Disinfection GuideCare of Mop -Clean with hot water and detergent... [/fig_ref].

## Donning and doffing ppe
An essential part of PPE is the proper way of putting it on (Donning) and removing (Doffing) as the maximum chances of contamination and infection occur during doffing. The steps and sequence of donning and doffing of N-95 masks and PPE are given in [fig_ref] Table I: Decontamination and Disinfection GuideCare of Mop -Clean with hot water and detergent... [/fig_ref]. All PPE components, especially face masks are effective only when used in combination with frequent hand hygiene.

## Type of exposure and use of ppe for hcw
Every patient should be taken as a COVID-19 suspect unless proven otherwise. Appropriate PPE should be universally worn when attending to any patient, even in a non-COVID-19 centre.
- In non-aerosol generation areas -head cap, face mask, goggles, and gloves.
- For aerosol generation areas and procedures -In addition, wear body gowns, shoe cover, and face shield.
- While attending a proven COVID-19 patient -Full Hazmat suit PPE.
- Nonmedical staff not in direct contact with patientstriple-layer surgical masks and gloves inside the clinic. They must maintain physical distancing and frequently use hand hygiene.

## Patient ppe
- All patients and their attendants should wear a mask.
- Using a triple layer surgical mask or N-95, if possible, significantly reduces the risk of transmission.

## Adjuncts to ppe
- Patients often complain that the doctor is not audible with PPE. One adjunct is to use a wireless or wired mini personal voice amplifier
- The use of the mobile phone is inevitable but often results in the breach of PPE. Hence, using a blue tooth device, preferably with bone conduction that doesn't plug the ear, is advised.
- Rexene covers or disposable paper covers/sheets for the patient sitting/lying areas.
- Contactless/foot operated dispensers for soap/ sanitizer/water in washbasins.

## Sanitization recommendations
Despite consistent evidence of contamination of various surfaces with SARS CoV 2 virus, especially in the hospital setting, there is no direct evidence of fomites being a cause of transmission.However, it is imperative to follow some necessary sanitization precautions for the decontamination/disinfection of COVID-19, as given in [fig_ref] Table I: Decontamination and Disinfection GuideCare of Mop -Clean with hot water and detergent... [/fig_ref]. These are based on the Hospital Infection Prevention and Control guidelines drafted by the National Centre for Disease Control and the WHO.Spraying and Fogging
Spraying, fogging, misting, or fumigation of rooms or surfaces is not recommended for COVID-19. Spraying of chemicals is harmful, affecting the mucus membrane, skin, and respiratory system. The recommended method is to wipe with a disinfectant soaked cloth

## Hand hygiene
Patients, attendants, and HCW's are advised to wash hands with soap and water in a washbasin with footoperated or motion sensor adapted taps. Everyone should use Foot-operated hand sanitizer dispensers before entering the clinic.

## Sanitizers
The composition of sanitizers is 60-70% ethanol or isopropyl alcohol. Avoid methanol containing or nonalcohol based sanitizers. Foot operated and Contactless sanitizer delivery systems are safe and effective.

## Heating ventilation and air conditioning (hvac)
Maintaining the HVAC plays a vital role in providing a stress-free, comfortable, and safe environment for patients and health care workers. Maintaining indoor air quality is very important to prevent cross-contamination and hospital-acquired infections. VOLUME 58 __ APRIL 15, 2021 INDIAN ACADEMY OF PEDIATRICS PRACTISING SAFELY DURING COVID-19 2) It is a misconception that if we maintain moderate humidity, the virus growth and propagation can be prevented. Unfortunately, this virus seems to be very resistant to environmental changes like temperature and humidity. It requires an extreme relative humidity of more than 80 percent and a temperature of more than 50 degrees Centigrade to control. These conditions are neither attainable nor acceptable.Air changes per hour (ACR)
Air changes per hour (ACR) are the number of total replacements of any room's air in one hour. If the air supply by the HVAC system in one hour is equal to the volume of the space, then it is called one air change per hour. The number of air exchanges required to clean the air depends on the quantum of infected aerosol production. For example, a minimum of 12 ACR is needed in the Intensive Care Unit (ICU). In contrast, only 4 ACR is required for general wards, as the expected amount of aerosol production is different in both areas.
There are two ways to reduce the quantum of infection in contaminated air, either by 'diluting' the pathogen (dilution ventilation) or by removing the pathogen (exhaust ventilation). Dilution Ventilation is also called positive pressure isolation, required to prevent infection in an immunocompromised patient. Exhaust Ventilation is called negative pressure isolation and is used primarily to avoid a contaminated patient's airborne disease [15] [fig_ref] Figure 1: Principle of HVAC to prevent airborne spread [/fig_ref].

## Ways to create air exchanges via exhaust
Ventilation:

## 1) cross ventilation by opening up doors and windows:
This is the cheapest way, but by this method, we cannot control the thermal and pollution level.
2) Exhaust Fan: The exhaust fan creates a negative pressure in the room, which sucks the dirty and contaminated air out of the room, and fresh air is pulled to replace it.
3) Fully Controlled Air: Air inlet, as well as exhaust air, is fully controlled, including the temperature and filtration. This requires a lot of resources, including technology, and is best suited for negative pressure isolation wards and ICUs.

## 4) air purifying systems:
This cleans the air either via filtration (e.g., HEPA) or via other techniques like ultraviolet rays. Recirculation of air has to be prevented for this system to be effective.
The airflow should be in the direction of clean to dirty and should not be directed towards the patient as it causes turbulence. [fig_ref] Figure 2: Clinic setting -Placement of exhaust fan, one feet above the ground [/fig_ref] 

## Plasma purifiers
Plasma purifiers are specialized newer technology air purifiers. Originally these purifiers were very large and cumbersome, however, with significant advancements in technology, they have become compact and a part of the HVAC with the ionization tubes mounted in the air conditioning, either in the unit itself or in the ductwork. These ionization tubes form ions (negatively or positively charged particles) as air circulates over them. The ions that are produced act in three ways to purify the air:
1) Sterilize bacteria and mould. When bacteria, virus and spores of mould come in contact with the ions, they are oxidized and destroyed. They can no longer multiply and are eliminated from the air.
2) Reduce particles in the air. The ions produced by the system bond with the toxins in the air, causing these particles to become larger. That makes them easier to be capture in the filters, reducing the number of toxin particles in the air.
3) Control odors. Odors associated with household aerosols or cleaning products are "captured" by the ions, oxidized, and eliminated.
The viricidal properties of the Plasma purifiers may be used while installing the HAVAC in the clinics and small establishments. However further evidence is required regarding its efficacy during this pandemic.

## Recommended hvac modifications for healthcare facilities:
Different recommendations for HVAC for various healthcare facilities are given in [fig_ref] Table I: Decontamination and Disinfection GuideCare of Mop -Clean with hot water and detergent... [/fig_ref] and [fig_ref] Figure 1: Principle of HVAC to prevent airborne spread [/fig_ref].

## Covid-19 exposure in a non-covid health facility
There are various situations where a Non-COVID-19 facility is faced with a COVID-19 challenge. The possible problems and recommendations are enumerated.
When patients admitted for unrelated/non-respiratory illness turn out to be COVID-19 positive

## Definition of contacts
A contact is a person who is likely to get the infection from a positive case through any of the following modes of transmission - Anyone exposed to a COVID -19 positive case 2 days before and 14 days after the onset of symptoms or date of testing The risk assessment of close contacts with COVID-19 patients is given in [fig_ref] Table I: Decontamination and Disinfection GuideCare of Mop -Clean with hot water and detergent... [/fig_ref].

## Recommendations for monitoring based on covid-19 exposure risk [17]

## High-and medium-risk exposure category
- HCW in the high-or medium-risk category should undergo active monitoring, including restriction from work in any healthcare setting until seven days after their last exposure.
[18]
- High-risk contacts will be quarantined for seven days
- Test for COVID-19 done on day 0 of exposure and if negative day 7 of exposure - If they test positive but are asymptomatic, they will follow the protocol for mild/pre-symptomatic cases - If they test negative and are asymptomatic, they should complete a 7-day quarantine from the last date of exposure and then return to work. Further, they should be in self-reporting observation at work for another minimum of 7 days and strictly abide by the mask and physical distancing rules.
- If they develop a fever (measured temperature > 100F or subjective fever) OR respiratory symptoms consistent with COVID-19 (e.g., cough, shortness of breath, sore throat), they should immediately test and self-isolate and notify the senior staff to take further action.

## Low-risk exposure category
- HCW in the low-risk category should perform selfmonitoring with delegated supervision until 14 days after the last potential exposure.
- Asymptomatic HCW in this category are not restricted from work.
- They should check their temperature twice daily and remain alert for respiratory symptoms consistent with COVID-19 (e.g., cough, shortness of breath, sore throat)
- Test for COVID-19 between day 5 and 14 of exposure - Suppose they develop a fever (measured temperature > 100F or subjective fever) OR respiratory symptoms. In that case, they should immediately self-isolate (separate themselves from others) and notify the staff physician promptly so that they can coordinate consultation and referral to a healthcare provider for further evaluation.
Disclaimer: This practice guideline is intended to assist pediatricians and their support staff in safely practicing during the COVID-19 pandemic. The guideline at best serves as a quick reference providing practical advice on continuing medical practice in a safe way in clinics and small establishments. This is a broad advisory and is not intended to override any local or national government policies. This guideline is based on the currently available evidence on COVID-19 and its applicability in the Indian context. With any further developments, the guideline will be subjected to change.
Contributors: SC, DG, AB, GVB: conception and design of the work and drafting the work; BJP, SSK, SD, PN, NS, AB, AJC: substantial contributions to the acquisition and interpretation of data for the work, and revising it critically for important intellectual content. All authors provided approval for the final version to be published. Funding: None; Competing Interests: None stated.
[fig] Figure 1: Principle of HVAC to prevent airborne spread. [/fig]
[fig] Figure 2: Clinic setting -Placement of exhaust fan, one feet above the ground. Direction of air should be from clean to dirty (patient side). Flow of AC air should be directed towards celling. VOLUME 58 __ APRIL 15, 2021 INDIAN ACADEMY OF PEDIATRICS PRACTISING SAFELY DURING COVID-19 [/fig]
[table] Table I: Decontamination and Disinfection GuideCare of Mop -Clean with hot water and detergent solution, disinfect it with sodium hypochlorite and keep for drying upside down Drying the floors with a separate drying mop should be done a NaClO = Sodium hypochlorite, b ABR=Alcohol based rub. VOLUME 58 __ APRIL 15, 2021 [/table]