Handbook of COVID-19 Prevention and Treatment

Handbook of COVID-19 Prevention and Treatment

Compiled According to Clinical Experience

The First Aliated Hospital, Zhejiang University School of Medicine

Editor’s Note:

Faced with an unknown virus, sharing and collaboration are the best remedy.

The publication of this Handbook is one of the best ways to mark the courage and wisdom our

healthcare workers have demonstrated over the past two months.

Thanks to all those who have contributed to this Handbook, sharing the invaluable experience

with healthcare colleagues around the world while saving the lives of patients.

Thanks to the support from healthcare colleagues in China who have provided experience that

inspires and motivates us.

Thanks to Jack Ma Foundation for initiating this program, and to AliHealth for the technical

support, making this Handbook possible to support the fight against the epidemic.

The Handbook is available to everyone for free. However, due to the limited time, there might be

some errors and defects. Your feedback and advice are highly welcomed!

Prof. Tingbo LIANG

Editor-in-Chief of the Handbook of COVID-19 Prevention and Treatment

Chairman of The First Affiliated Hospital, Zhejiang University School of Medicine

Foreword

This is an unprecedented global war, and mankind is facing the same enemy, the novel coronavirus.

And the first battlefield is the hospital where our soldiers are the medical workers.

To ensure that this war can be won, we must first make sure that our medical staff is guaranteed

sufficient resources, including experience and technologies. Also, we need to make sure that the

hospital is the battleground where we eliminate the virus, not where the virus defeats us.

Therefore, the Jack Ma Foundation and Alibaba Foundation have convened a group of medical

experts who have just returned from the frontlines of fighting the pandemic. With the support of

The First Affiliated Hospital, Zhejiang University School of Medicine (FAHZU), they quickly

published a guidebook on the clinical experience of how to treat this new coronavirus. The

treatment guide offers advice and reference against the pandemic for medical staff around the

world who are about to join the war.

My special thanks goes out to the medical staff from FAHZU. While taking huge risks in treating

COVID-19 patients, they recorded their daily experience which is reflected in this Handbook. Over

the past 50 days, 104 confirmed patients have been admitted to FAHZU, including 78 severe and

critically ill ones. Thanks to the pioneering efforts of medical staff and the application of new

technologies, to date, we have witnessed a miracle. No staff were infected, and there were no

missed diagnosis or patient deaths.

Today, with the spread of the pandemic, these experiences are the most valuable sources of

information and the most important weapon for medical workers on the frontline. This is a

brand-new disease, and China was the first to suffer from the pandemic. Isolation, diagnosis,

treatment, protective measures, and rehabilitation have all started from scratch. WE hope that

this Handbook can provide doctors and nurses in other affected areas valuable information so

they don’t have to enter the battlefield alone.

This pandemic is a common challenge faced by mankind in the age of globalization. At this

moment, sharing resources, experiences and lessons, regardless of who you are, is our only

chance to win. The real remedy for this pandemic is not isolation, but cooperation.

This war has just begun.

Handbook of COVID-19 Prevention and Treatment

Contents

Part One Prevention and Control Management

I. Isolation Area Management......................................................................................................1

II. Staff Management..................................................................................................................4

III. COVID-19 Related Personal Protection Management.............................................................5

IV. Hospital Practice Protocols during COVID-19 Epidemic...........................................................6

V. Digital Support for Epidemic Prevention and Control..............................................................16

Part Two Diagnosis and Treatment

I. Personalized, Collaborative and Multidisciplinary Management.............................................18

II.Etiology and Inflammation Indicators.....................................................................................19

III. Imaging Findings of COVID-19 Patients................................................................................21

IV. Application of Bronchoscopy in the Diagnosis and Management of COVID-19 Patients........22

V. Diagnosis and Clinical Classification of COVID-19..................................................................22

VI. Antiviral Treatment for Timely Elimination of Pathogens......................................................23

VII. Anti-shock and Anti-hypoxemia Treatment..........................................................................24

VIII. The Rational Use of Antibiotics to Prevent Secondary Infection...........................................29

IX. The Balance of Intestinal Microecology and Nutritional Support...........................................30

X. ECMO Support for COVID-19 Patients.....................................................................................32

XI. Convalescent Plasma Therapy for COVID-19 Patients............................................................35

XII. TCM Classification Therapy to Improve Curative Efficacy.......................................................36

XIII. Drug Use Management of COVID-19 Patients......................................................................37

XIV. Psychological Intervention for COVID-19 Patients................................................................41

XV. Rehabilitation Therapy for COVID-19 Patients.......................................................................42

XVI. Lung Transplantation in Patients with COVID-19.................................................................44

XVII. Discharge Standards and Follow-up Plan for COVID-19 Patients........................................45

Part Three Nursing

I. Nursing Care for Patients Receiving High-Flow Nasal Cannula (HFNC) Oxygen Therapy..........47

II. Nursing Care in Patients with Mechanical Ventilation.............................................................47

III. Daily Management and Monitoring of ECMO (Extra Corporeal Membrane Oxygenation).......49

IV. Nursing Care of ALSS (Artificial Liver Support System)...........................................................50

V. Continuous Renal Replacement Treatment (CRRT) Care..........................................................51

VI. General Care.........................................................................................................................52

Appendix

I. Medical Advice Example for COVID-19 Patients.......................................................................53

II. Online Consultation Process for Diagosis and Treatment.......................................................57

References........................................................................................................................................ ..........59

Handbook of COVID-19 Prevention and Treatment

Part One Prevention and

Control Management

I. Isolation Area Management

1

Fever Clinic

1.2 Zone Arrangement

(1) Set up an independent examination room, a laboratory, an observation room, and a

resuscitation room;

(2) Set up a pre-examination and triage area to perform preliminary screening of patients;

(3) Separate diagnosis and treatment zones: those patients with an epidemiological history

and fever and/or respiratory symptoms shall be guided into a suspected COVID-19 patient

zone; those patients with regular fever but no clear epidemiological history shall be guided

into a regular fever patient zone.

1.3 Patient Management

(1) Patients with fevers must wear medical surgical masks;

(2) Only patients are allowed to enter the waiting area in order to avoid overcrowding;

(3) The duration of the patient’s visit shall be minimized so as to avoid cross infections;

(4) Educate patients and their families about early identification of symptoms and essential

preventative actions.

1.1 Layout

(1) Healthcare facilities shall set up a relatively independent fever clinic including an

exclusive one-way passage at the entrance of the hospital with a visible sign;

(2) The movement of people shall follow the principle of “three zones and two passages”:

a contaminated zone, a potentially contaminated zone and a clean zone provided

and clearly demarcated, and two buffer zones between the contaminated zone and the

potentially contaminated zone;

(3) An independent passage shall be equipped for contaminated items; set up a visual

region for one-way delivery of items from an office area (potentially contaminated zone) to

an isolation ward (contaminated zone);

(4) Appropriate procedures shall be standardized for medical personnel to put on and take

off their protective equipment. Make flowcharts of different zones, provide full-length

mirrors and observe the walking routes strictly;

(5) Infection prevention and control technicians shall be assigned to supervise the medical

personnel on putting on and removing protective equipment so as to prevent contamination;

(6) All items in the contaminated zone that have not been disinfected shall not be removed.

Handbook of COVID-19 Prevention and Treatment

1.4 Screening, Admission and Exclusion

(1) All healthcare workers shall fully understand the epidemiological and clinical features of

COVID-19 and screen patients in accordance with the screening criteria below (see Table 1);

(2) Nucleic acid testing (NAT) shall be conducted on those patients who meet the screening

criteria for suspected patients;

(3) Patients who do not meet the screening criteria above, if they do not have a confirmed

epidemiological history, but cannot be ruled out from having COVID-19 based on their

symptoms, especially through imaging, are recommended for further evaluation and to obtain a

comprehensive diagnosis;

(4) Any patient who tests negative shall be re-tested 24 hours later. If a patient has two negative

NAT results and negative clinical manifestations, then he or she can be ruled out from having

COVID-19 and discharged from the hospital. If those patients cannot be ruled out from having

COVID-19 infections based on their clinical manifestations, they shall be subjected to additional

NAT tests every 24 hours until they are excluded or confirmed;

(5) Those confirmed cases with a positive NAT result shall be admitted and treated collectively

based on the severity of their conditions (the general isolation ward or isolated ICU).

Table 1 Screening Criteria for Suspected COVID-19 Cases

Epidemiological

History

Clinical

Manifestations

Suspected Case Diagnosis Yes Yes

① Within 14 days before the onset of the disease, the patient

has a travel or residence history in the high-risk regions or

countries;

② Within 14 days before the onset of the disease, the patient

has a history of contact with those infected with SARS-CoV-2

(those with a positive NAT result);

③ Within 14 days before the onset of the disease, the patient

had direct contact with patients with fever or respiratory

symptoms in high-risk regions or countries;

④ Disease clustering (2 or more cases with fever and/or

respiratory symptoms occur at such places as homes, offices,

school classrooms, etc. within 2 weeks).

The patient

meets 1

epidemiological

history and

2 clinical

manifestations.

The

patient

has no

epidemiological

history

and

meets 3

clinical

manifestations.

The patient has

no epidemiological

history,

meets 1-2

clinical

manifestations,

but cannot be

excluded from

COVID-19

through

imaging.

① The patient has fever and/or respiratory symptoms;

② The patient has the following CT imaging features of

COVID-19: multiple patchy shadows and interstitial changes

occur early, particularly at the lung periphery. The conditions

further develop into multiple ground-glass opacities and

infiltrates in both lungs. In severe cases, the patient may have

lung consolidation and rare pleural effusion;

③ The white blood cells count in the early stage of the disease

is normal or decreased, or the lymphocyte count decreases

over time.

Expert

consultation

2 Handbook of COVID-19 Prevention and Treatment

3

2.1 Scope of Application

The isolation ward area includes an observation ward area, isolation wards, and an

isolation ICU area. The building layout and workflow shall meet the relevant requirements

of the hospital isolation technical regulations. Medical providers with negative pressure

rooms shall implement standardized management in accordance with relevant requirements.

Strictly limit access to isolation wards.

2.2 Layout

Please refer to fever clinic.

2.3 Ward Requirements

(1) Suspected and confirmed patients shall be separated in different ward areas;

(2) Suspected patients shall be isolated in separated single rooms. Each room shall be

equipped with facilities such as a private bathroom and the patient’s activity should be

confined to the isolation ward;

(3) Confirmed patients can be arranged in the same room with bed spacing of not less than

1.2 meters (appx 4 feet). The room shall be equipped with facilities such as a bathroom and

the patient’s activity must be confined to the isolation ward.

2.4 Patient Management

(1) Family visits and nursing shall be declined. Patients should be allowed to have their

electronic communication devices to facilitate interactions with loved ones;

(2) Educate patients to help them prevent further spread of COVID-19, and provide instructions

on how to wear surgical masks, proper handwashing, cough etiquette, medical

observation and home quarantine.

Isolation Ward Area

Handbook of COVID-19 Prevention and Treatment

II. Staff Management

Workflow Management

(1) Before working in a fever clinic and isolation ward, the staff must undergo strict training

and examinations to ensure that they know how to put on and remove personal protective

equipment. They must pass such examinations before being allowed to work in these

wards.

(2) The staff should be divided into different teams. Each team should be limited to a maximum

of 4 hours of working in an isolation ward. The teams shall work in the isolation

wards (contaminated zones) at different times.

(3) Arrange treatment, examination and disinfection for each team as a group to reduce the

frequency of staff moving in and out of the isolation wards.

(4) Before going off duty, staff must wash themselves and conduct necessary personal hygiene

regimens to prevent possible infection of their respiratory tracts and mucosa.

Health Management

(1) The front-line staff in the isolation areas – including healthcare personnel, medical

technicians and property & logistics personnel – shall live in an isolation accommodation

and shall not go out without permission.

(2) A nutritious diet shall be provided to improve the immunity of medical personnel.

(3) Monitor and record the health status of all staff on the job, and conduct health monitoring

for front-line staff, including monitoring body temperature and respiratory symptoms;

help address any psychological and physiological problems that arise with relevant experts.

(4) If the staff have any relevant symptoms such as fever, they shall be isolated immediately

and screened with an NAT.

(5) When the front-line staff including healthcare personnel, medical technicians and property

& logistics personnel finish their work in the isolation area and are returning to normal life,

they shall first be NAT tested for SARS-CoV-2. If negative, they shall be isolated collectively at

a specified area for 14 days before being discharged from medical observation.

4 Handbook of COVID-19 Prevention and Treatment

5

III. COVID-19 Related Personal Protection Management

Protection Level

Level I

protection

Level II

protection

Level III

protection

Protective Equipment Scope of Application

· Pre-examination triage,

general outpatient department

Notes:

1. All staff at the healthcare facilities must wear medical surgical masks;

2. All staff working in the emergency department, outpatient department of infectious diseases,

outpatient department of respiratory care, department of stomatology or endoscopic examination

room (such as gastrointestinal endoscopy, bronchofibroscopy, laryngoscopy, etc.) must

upgrade their surgical masks to medical protective masks (N95) based on Level I protection;

3. Staff must wear a protective face screen based on Level II protection while collecting respiratory

specimens from suspected/confirmed patients.

· Disposable surgical cap

· Disposable surgical mask

· Work uniform

· Disposable latex gloves

or/and disposable isolation

clothing if necessary

· Disposable surgical cap

· Medical protective mask (N95)

· Work uniform

· Disposable medical protective

uniform

· Disposable latex gloves · Goggles

· Fever outpatient department

· Isolation ward area (including isolated

intensive ICU)

· Non-respiratory specimen examination

of suspected/confirmed patients

· Imaging examination of suspected/

confirmed patients

· Cleaning of surgical instruments used

with suspected/confirmed patients

· Disposable surgical cap

· Medical protective mask (N95)

· Work uniform

· Disposable medical protective

uniform

· Disposable latex gloves

· Full-face respiratory protective

devices or powered air-purify

ing respirator

· When the staff performs operations

such as tracheal intubation,

tracheotomy, bronchofibroscope,

gastroenterological endoscope, etc.,

during which, the suspected/confirmed

patients may spray or splash respiratory

secretions or body fluids/blood

· When the staff performs surgery and

autopsy for confirmed/suspected

patients

· When the staff carries out NAT for COVID-19

Handbook of COVID-19 Prevention and Treatment

6. Put on goggles and

protective clothing

7. Put on disposable

latex gloves

3. Put on a disposable

surgical cap

8. Donning

completed

4. Put on a medical

protective mask (N95)

5. Put on inner disposable

nitrile/latex gloves

2. Wash hands

IV. Hospital Practice Protocols during COVID-19 Epidemic

1. First put on special work

clothes and work shoes

Guidance on Donning and Removing Personal Protective Equipment (PPE) to

manage COVID-19 Patients

Protocol for Donning PPE:

Put on special work clothes and work shoes → Wash hands → Put on disposable surgical cap →

Put on medical protective mask (N95) → Put on inner disposable nitrile/latex gloves → Put on

goggles and protective clothing (note: if wearing protective clothing without foot covers, please

also put on separate waterproof boot covers), put on a disposable isolation gown (if required in

the specific work zone) and face shield/powered air-purifying respirator(if required in the

specific work zone) → Put on outer disposable latex gloves