¶ Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases
Translation Section Editors
Prof. Wang-Huei Sheng, M.D. PhD
¶ I. Preface
As the COVID-19 pandemic continues to progress and nosocomial cluster had been reported in Taiwan, “Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases” is formulated, in order to provide guidance for management of confirmed cases or nosocomial cluster events in hospitals. However, as the pandemic progressed, countries including China, Korea, and the Netherlands had taken emergent measures such as temporarily shutting down hospitals in response to large scale nosocomial outbreaks. In response to these issues, operational control measures are proposed to prevent an uncontrollable hospital cluster event after initial intervention. Hospitals are advised to develop corresponding contingency plans based on this proposal and conduct rehearsals to ensure immediate response to protect the benefits of patients and staff.
¶ II. The general control principles
- If two COVID-19 disease cluster events were reported within 14 days at a hospital, countermeasures should be taken according to “Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases”. The hospital should also consult with relevant health authorities or the communicable disease control medical network (CDCMN) regional commander for further actions.
- If third or more COVID-19 disease cluster events were reported of the above hospital, the district health bureau should conduct epidemiological surveys, initiate an extended “operational control” or “clearing control” (Table 1) if necessary, and determine details of control measures (i.e. region and workflow) depending on subsequent situations. The local health bureau should consult with the CDCMN regional commander if necessary.
- Operational Control Protocol
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Activation criteria
- Cluster events in at least 3 wards/units i, ii within a building unconnected to any other buildings i.Cluster events in at least 3 wards/units i, ii within a building unconnected to any other buildings i.
- Criteria 1 is not fulfilled (i.e. only 1 ward/unit had a cluster event, but the other 2 wards/units had only 1 new confirmed case, or the 3rd cluster event occurred more than 14 days after the previous cluster event or in a different building), while the epidemiological surveys suggest extended control measures are necessary, the district health bureau may initiate “operational control” or “clearing control” protocol, after consulting the regional commander of CDCMN.
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Control period
- Starting date: the day when control activation criteria are met or as notified by the district health bureau or the commander of CDCMN.
- Ending date: 28 days after the last confirmed case in the controlled area had been quarantined/transferred.
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Controlled area
- The building that has met the activation criteria and is not connected to any other building
- When the affected building is connected with other buildings (i.e. via overhead bridges, corridors, basements, lobbies, etc.) or single cluster events are reported in different buildings within the same compound, the health authority or the commander of CDCMN should determine the control area.
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Control principles
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Suspend operations, stop receiving patients in the outpatient’s unit, ward or dialysis center.
- Patients iii, iv with stable clinical conditions should be discharged, transferred to unaffected areas, or transferred to a different hospital as soon as possible, in accordance with the referral/discharge schedule in Table 2 below, and in coordination with the health authorities.
- The hospital shall suspend outpatient service (i.e. new appointments, medical treatment, health examination, health education, rehabilitation department, etc.) while patients with major or special medical needs (e.g. outpatient chemotherapy, special medication application, etc.) shall be referred or transferred to other unaffected unit; appointments or examinations that have been scheduled before operational control may be proceeded iii.
- The dialysis center iii, iv may continue to provide service for current patients and new patients with dialysis needs held in the control area.
- The emergency department iii should only accept critical patients and transfer the patient to another hospital or to an unaffected unit when the patient is stable.
- The operating room, cardiac catheterization room, radiology department, etc iii, iv>, should not accept new appointments except for emergency or necessary surgeries/examinations; surgeries and examinations that had been scheduled before the control may be proceeded.
- For further details, kindly refer to section “III. Notice for other hospitals” and “IV. Infection control measures for each unit during the control period”.
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Suspend operations, stop receiving patients in the outpatient’s unit, ward or dialysis center.
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Activation criteria
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Clearing control Protocol
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Activation criteria
- In addition to initiating operational control, 1 additional confirmed case was reported in a different ward or unit i, ii within the same building i.
- Criteria 1 unmet (i.e. only 2 wards/units have a cluster event but only 1 new confirmed case in other 2 wards or units, the 3rd cluster event occurred more than 14 days after the previous cluster event or in a different building, etc.), while the epidemiological surveys suggest extended control measures are necessary, the local health bureau may initiate protocols for operational control or clearing control, after consulting the CDCMN regional commander.
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Duration
- Starting date: the date when activation criteria are met or as notified by the district health bureau or CDCMN regional commander.
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Ending date:
- 28 days after the last confirmed case in the controlled area had been quarantined or transferred.
- If all patients had been transferred out of the control area and disinfection operations had been completed, the hospital may submit relevant environmental inspection plans and test results to the local health bureau or the CDCMN regional commander for evaluation, to determine the ending date of control vi. Area
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Area
- The building that meets the activation criteria and is not connected to any other buildings.
- When the affected building is connected to other buildings (i.e. via overhead bridges, corridors, basements, lobbies, etc.) or isolated cluster events are reported in different buildings within the same compound, health authority or the CDCMN regional commander is responsible for determining the extent of the area.
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Control principles
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Clear out ward and emergency department within the control area.
- Patients with appropriate clinical conditions should be discharged, transferred to unaffected areas, or transferred to a hospital as soon as possible, in accordance with the referral or discharge schedules listed in Table 2 below, and in coordination with relevant health authorities iii, iv, vi.
- If emergency service of the affected hospital is crucial for critical care in the surrounding region, the duration of lockdown may be shortened. After all emergency patients had been transferred out of the hospital and disinfection operations had been completed, the hospital may submit relevant environmental inspection plans and test results to the district health bureau or the CDCMN regional commander for evaluation vi, and partially resume the emergency services. In such scenarios, only patients with acute and critical conditions should be admitted for initial treatment. Once condition stabilizes, patients should be referred to other hospitals or unaffected units.
- Shut down all medical services iv (i.e. outpatient departments, examination facilities, laboratories, operation rooms, etc.) within the control area, except for emergency, major, or specific irreplaceable services. The hospital should refer patients with major or special medical needs (e.g. tumor removal surgery, chemotherapy, special drug application, etc.) and those receiving long term hemodialysis iii, iv, vi to unaffected hospitals or units for further treatment.
- The hospital should report any difficulty encountered during implementation of disease control measures to relevant authorities and request for assistance if needed.
- For further details, kindly refer to sections “III. Notice for other hospitals” and “IV. Infection control measures for each unit during the control period”
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Clear out ward and emergency department within the control area.
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Activation criteria
¶ Remarks
- The local health department shall determine a disease cluster event and the affected area based on the epidemiological survey. Consult the CDCMN regional commander when necessary.
- New clustering events or new confirmed cases occurred within 14 days after the last clustering event.
- Referred to units without clustering event.
- If patients in the hospital area have urgent medical needs for corresponding units (i.e. intensive care unit, respiratory care center, operating room, cardiac catheterization unit, radiology department, dialysis center, etc.) are located within the controlled area (with the exception of urgent or necessary medical treatment that cannot be postponed), under the principle of disease control protocol, refer/discharge stable patients to unaffected units. Meanwhile, reduce OPD capacities for unaffected units and avoid transferring the patients into the controlled area. If medical treatment within a controlled area is inevitable, the hospital shall, with the exception of emergency, submit a proposal to the local health department, regarding infection control measures such as workplace management, schedule, disinfection procedure, and location of the inpatient ward (if a disease cluster happened in the requisite unit, relevant environmental inspection plan and test results after the disinfection procedure, should be submitted along with the proposal). The local health department or regional commander of CDCMN shall evaluate the proposal based on actual circumstances and limitations. After receiving approval, the hospital may proceed with the transfer following the instructions from the authority.
- New confirmed cases refer to patients who were not suspected or diagnosed prior to admission, but were confirmed after admission, or staff who continued to work after the onset of illness.
- Considering that the spatial configuration or the divisional quarantine of the relevant units in hospitals may vary, and that whether the clinical conditions of the patients in the units are suitable for transfer or whether the actual capacity of the units or hospitals receiving patients after referral/exit may vary, the practices, procedures, and scope of measures to control the emptying of units, referral/exit, cleaning and disinfection of environmental facilities, and inspection, etc., the hospital shall follow the instructions of the competent health authorities or the infectious disease prevention and treatment network commander after assessing the actual situation of the cluster epidemic.
Table 1. Proposed Measures for Operation Control and Clearance Control in Response to the COVID-19 Cluster Incident in the Hospital
| Operational control | Clearance control | |
|---|---|---|
| Activation criteria 1 | Cluster events in at least 3 wards/units(a) within a building which is not connected to any other buildings 5,6. | In addition to the initiation of operational control, 1 additional confirmed case was reported in a different ward/unit within the same building 6,8. |
| Control area | 1. The building that has met the activation criteria and is not connected to any other building. 2. When the affected building is connected to other buildings (i.e. via overhead bridges, corridors, basements, lobbies, etc.) or single cluster events are reported in different buildings within the same compound, the health authority or the commander of CDCMN should determine the control area. |
|
| Principle 2 | Suspend irrelevant operation; the inpatient, outpatient and dialysis units will cease receiving new patients. | 1. Control measures for "operational control".2. Removed of all patients in the control area10. |
| Emergency Department3 | Admit only patients with acute and critical illnesses for initial emergency treatment, and after stabilization, arrange transfer to other hospitals or non-controlled units. | Stop admitting new patients and execute clearance protocol9,10. |
| Inpatient units3,4 | Discharge patients as soon as possible. | Discharge or transfer the patients as soon as possible 10. |
| Outpatient units and others3,4 | 1. Appointments for treatment or chronic hemodialysis that was made prior to the control may be continued. 2. Patients with significant and special medical needs shall be referred to an unaffected unit. |
1. All medical treatment shall be suspended except for those that are substantially necessary and cannot be referred. 2. Patients with significant and special medical needs (i.e. chronic hemodialysis) should be assisted in making referrals10 or redirected to an unaffected unit. |
| Control Period | Starting Date: Proposed in principle as the date of compliance with the control commencement conditions7. Ending date: 28 days from the day after the last confirmed case in the control area had been quarantined /transferred out. |
Starting date: Proposed in principle as the date of compliance with the controlled start conditions7. Ending Date11: 28 days from the day after the last confirmed case in the control area had been quarantined /transferred out. |
2. If multiple disease clusters were confirmed within the hospital, corresponding response protocol may be amended accordingly by the regional commander of the Communicable Disease Control Medical Network (CDCMN) or district public health bureau. Actual circumstances and factors should be taken into consideration, including, but not limited to, ward capacity, division quarantine, size of the district, clinical conditions of individual patient, capacity of referral hospital.
3. Referred to units without clustering event.
4. If patients in the hospital area have urgent medical needs while corresponding units (i.e. intensive care unit, respiratory care center, operating room, cardiac catheterization unit, radiology department, dialysis center, etc.) are located within the controlled area (with the exception of urgent or necessary medical treatment that cannot be postponed), under the principle of disease control protocol, refer/discharge patients who are in stable condition to an unaffected unit. At the meantime, reduce appointments for unaffected units and avoid transferring the patients into the controlled area. If medical treatment within a controlled area is inevitable, the hospital shall, with the exception of emergency, submit a proposal to the local health department, regarding infection control measures such as workplace management, schedule, disinfection procedure, and location of the inpatient ward (if a disease cluster happened in the requisite unit, relevant environmental inspection plan and test results after the disinfection procedure, should be submitted along with the proposal). The local health department or regional commander of CDCMN shall evaluate the proposal based on actual circumstances and limitations. After receiving approval, the hospital may proceed with the transfer following the instructions from the authority.
5. The local health department shall determine a disease cluster event and the affected area based on the epidemiological survey. Consult the regional commander of CDCMN whenever necessary.
6. New clustering events or new confirmed cases occurred within 14 days after the last clustering event.
7. the starting date will be determined by the local health department or the commander of CDCMN.
8. New confirmed cases are referring to patients who were not suspected or diagnosed prior to admission, but were confirmed after admission, or staff who continued to work after the onset of illness.
9. If the emergency service from the affected hospital is crucial for critical care in the district, the period of lockdown may be shortened. After all emergency patients had been transferred out of the hospital and the disinfection operation had been completed, the hospital may submit relevant environmental inspection plan and test results to the district health bureau or the regional commander of CDCMN for evaluation, to partially resume the emergency services. If the emergency service is resumed under this condition, only patients with acute and critical conditions should be admitted for initial treatment. The patients should be transfer to other hospitals or an unaffected unit once the patient is stable.
10. Kindly refer to Table 2-5, for corresponding referral criteria and procedures for individual unit according to the risk classification.
11. If all patients had been transferred out of the control area and disinfection operation had been completed, the hospital may submit relevant environmental inspection plan and test results to the district health bureau or the regional commander of CDCMN for evaluation, to determine the ending date of control.
¶ III. Other relevant issues
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Set up contingency center and assign mission
The hospital should be well prepared for the establishment of a contingency center and corresponding team in advance. During a controlled period, the hospital should immediately establish a contingency center, with the director hospital as the commander. Infectious disease physicians are recommended to serve as the safety officer or chief of staff (the actual title or work details may be tailored according to the established plan), who is responsible to assign missions and firmly in control of the following matters.- The planning of various manpower needs, duty management, supporting manpower training, including medical personnel (e.g., physicians, nurses, respiratory therapists, etc.), supporting medical personnel (e.g., medical laboratory, radiology, social welfare, nutrition, psychology, etc.), and administration office personnel (e.g., information personnel, administrative personnel, environmental control medical personnel, janitors), etc.
- Nosocomial outbreak surveillance, planning and auditing of infection control measures, etc.
- Planning of financial affairs, staff allowances, and duty management, etc.
- Transportation route planning: patient transfer out/in, staff on/off, hospital area shuttle bus routes, etc.
- Supplies of various types of materials, such as sanitary materials and pharmaceuticals, inspection materials, personal protective equipment, clothing and quilts, civilian materials (e.g., toilet paper, lunch boxes, tableware, etc.), food, drinking water, etc.
- Planning and maintenance of equipment and facilities: wards, operating rooms, examination rooms, air conditioning, water and electricity, gas lines, medical equipment, information equipment, mortuaries, staff dormitories, centralized quarantine/isolation facilities for staff, etc.
- Contingency plan for unavailability of manpower, handling of public opinion, protests, etc.
- Post-controlled area recovery plan, etc.
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Execution of hospital clearance protocol, divisional quarantine protocol and workplace management plan.
- All unit should actively execute all response protocol, especially units with reported, suspected or confirmed cases.
- Hospital should formulate and execute protocol for individual units, including, but not limited to, patient treatment plans, personal protection equipment protocol, resources and workplace management plan.
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Set up specialized unit/ward to contain suspected or confirmed cases within the hospital.
- Suspected cases and confirmed cases should be contained in different wards, except when it has exceeded the maximum capacity.
- The ward should be isolated and distant from other unaffected unit or ward, especially those with immunocompromised patients (i.e. gynecology, oncology), all contact should be avoided.
- Patient should be held in single room until the capacity is maxed up.
- Contaminated zone, intermediate zone and clear zone should be implemented into workplace management plan.
- Reasonable work shift and working area planning should be implemented to prevent workforce from exhaustion.
- Division of working forces and space should be implemented; all staff should only work within the designated region under synchronized shift schedule.
- Local health department should coordinate resources distribution, patient transfer and discharge, ward capacity of individual hospitals in the region, access control of the district, etc.
Figure 1. Implementation of zone of risks into workplace. (Journal of Hospital Infection 77 (2011) 332-337)
- Staff should wash hands at checkpoints before entering next zone.
- Protocol may be amended according to actual floor plan for inpatient unit in individual hospital, i.e., order of equipping PPE and the corresponding zone.
Figure 2 Specialized ward and workplace management plan.
- Before entering the specialized disease control unit, staff should wash hands and put on N95 mask; other PPE can be equipped the nursing station. The green line indicates the moving flow of working staff. The actual workplace planning should be designed to fit the actual set up for individual hospital.
- The red line indicates the moving flow of patients. The moving flow for staff and patient should not overlap to prevent contamination. However, the actual workplace planning should be designed according to the actual floorplan for individual hospital, in which as shown in the figure, there will be circumstance where the planning has to be compromised due to physical limitation.
¶ IV. Suggested Disease Control Protocol during Movement Control Policy
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Disease clusters reported unit
- If not more than 2 clusters were reported within the hospital, implement response protocol as according to “Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases”
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When more than 2 clusters had been reported, the local health department shall initiate “operational
control” or “clearance control” after thorough assessment. “Contingency recommendations for hospitals in
response to COVID-19 (Wuhan pneumonia) confirmed cases” are still applicable alongside with the
protocols. The following procedures are also recommended:
- All confirmed cases should be transferred to the specialized ward before “clearance control” protocol. All contacts ii should remain in the current unit until to be designated to a specialized unit. The affected unit should be disinfected completely after the lockdown.
- Personal protective equipment protocol is suggested to be compatible to working with confirmed cases, before all contacts are tested negative ii and the affected unit are disinfected completely.
- Patients who had been tested negative should be discharged or transfer to other unit or hospital. The current unit (or hospital) should inform the referral unit with the patient status and disease contact history.
- The referral hospital should educate the patient with hand hygiene and airway hygiene. The patients are required to wear mask at all time. All healthcare provider should practice standard precautions within the 14-day-health management of the patient. The patients should be held in single room or isolated from other unaffected unit until the end of self-health management ii.
- If there is manpower shortage due to staff practicing home isolation protocol, the hospital should report to local health department and request for backup. If no suitable substitutes was available due to the properties of the unit (i.e. required specific skills like resource center, dialysis center, accounting office, IT department, etc.) while the affected unit was crucial for daily operation of the hospital, staff from the affected unit may return to work under instruction of regional commander of CDCMN or local health department, if they had been tested negative or show no symptom of the disease.
- For further information, kindly refer to Table 2-5.
- If multiple disease clusters were confirmed within the hospital, corresponding response protocol may be amended accordingly by the regional commander of CDCMN or by local health department. Actual circumstances and factors should be taken into consideration, including, but not limited to, ward capacity, division quarantine, size of the district, clinical conditions of individual patient, capacity of referral hospital.
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Non-disease-cluster unit
- No new suspected case (including staff and patient) within 14 days prior to disease control protocol i:
- Discharge or transfer patients (to other hospital or an unaffected unit) as soon as possible, depending on the clinical condition of individual patients. Patients should be advised to practice self-health management ii for 14 days after leaving the unit.
- If the hospital arranged the transfer, the affected hospital is responsible to inform the referral hospital of the patient status prior to the transfer. The referral hospital should educate the patient with hand hygiene and airway hygiene. The patients are required to wear mask at all time. All healthcare provider should practice standard precautions within the 14-day-health management ii of the patient.
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Any new suspected case (including staff and patient) occurs in the unit within 14 days prior to disease
control protocol
iii:
- All working staffs (with minimum of one 8-hour shift) and patients (admitted or routinely treated) should be screened at least once. The hospital is advised to consult the regional commander of CDCMN through the local health department.
- If the suspected case is a patient: Proceed screening test on the subject according to “Program of community-based surveillance and test for COVID-19” iv, execute disease control protocol as confirmed case until proven otherwise.
- If the suspected case is a staff: Proceed screening test on the subject according to “"Advance Intrahospital Disease Control protocol” ii, the subject should take leave and practice self-health management until the test result has been confirmed.
- All other patients should stay in the unit until further notice. Proceed according to protocols listed in Table 2-5 after the test result has been confirmed.
- If there are more than 2 new suspected cases iii, all patient should be contained in the unit. The hospital should report to local health department immediately and execute epidemiology investigation with relevant examination.
- Kindly refer to Table 2-5 for suggested protocol according to different unit.
- If multiple disease clusters were confirmed within the hospital, corresponding response protocol may be amended accordingly by the regional commander CDCMN or by local health department. Actual circumstances and factors should be taken into consideration, including, but not limited to, ward capacity, division quarantine, size of the district, clinical conditions of individual patient, capacity of referral hospital.
- No new suspected case (including staff and patient) within 14 days prior to disease control protocol i:
¶ Remarks
- Applicable to ward, emergency department frequent return visit unit (>50% of patient revisit ≥ 3 times per week, e.g., for hemodialysis or physical therapy). Other unit (i.e. out-patient departments, radiology, administration office) will refer to “No new staff related suspected case after initiation of disease control protocol”. Staff refer to all working staff in the unit, with at least one 8-hour shift. Patient refer to all admitted or routinely treated patient in the unit.
- For further information, kindly refer to “Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases”
- Applicable to ward, emergency department frequent return visit unit (>50% of patient revisit ≥ 3 times per week, i.e. for hemodialysis or physical therapy). Other unit (i.e. out-patient departments, radiology, administration office) will refer to “No new staff related suspected case after initiation of disease control protocol”. Staff refer to all working staff in the unit, with at least one 8-hour shift. Patient refer to all admitted or routinely treated patient in the unit.
- For detailed workflow, kindly refer to "community-based surveillance program and confirmed case response protocol”
Table 2: Suggested control measures for inpatient units/emergency department in control area during the control period of nosocomial COVID-19 clustering event.
| Unit and Scenario | Management of New Suspected Patients | Expanded Testing and Inspection1,2 | Patient referral / transfer2,3 | Disinfection after lockdown2 | Backup required | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Patient | Staff | Situation | Targets | Timing of referral | Targets | Yes / No | Situation where PPE protocol should be compatible to confirmed cases | |||
| Disease cluster unit4 | Contacts5 / Risk group5 handle as reported cases | 5 / Risk group5 handle as reported cases | When ≥1 confirmed case among tested contacts | Risk group | Contact / Risk group were tested negative | Tested contactor / Risk group | Yes | Yes6 | Before disinfection and confirmation of test results for risk group within the affected unit | |
| Non-disease-cluster unit | Scenario A | N/A | N/A | N/A | N/A | Refer ASAP | All patients | No | No | N/A |
| Scenario B7 | According to "Program of community-based surveillance" | According to "Advance Intrahospital Disease Control protocol"8 | Suspected case tested negative | None | Suspected case tested negative | All patients | No11 | No | Treating suspected case before test result has been confirmed | |
| Suspected case tested positive | Risk group9 | Contact / Risk group were tested negative | Contact / Risk group10 | Before disinfection and confirmation of test results for risk group within the affected unit | ||||||
NA: not applicable, PPE: personal protective equipment, scenario A: no new suspected cases among patients or healthcare workers within the first 14 days of the control period, scenario B: new suspected cases among patients or healthcare workers within the first 14 days of the control period.
1. Expanded Risk Targets for Specimen collection: It is not mandatory for hospitals to examine discharged/non-hospitalized patients, their accompanying family members (accompanying for more than 8 hours), or staff members who have left the hospital, etc. However, a list of such patients or related personnel, if possible, should be acquired for follow-up investigation by the local health department.
2. Considering that there may be differences in the space allocation, partition, or differences in the size of districts among hospitals, or there may be a variety of situations and differences in the actual admission capabilities of hospitals that are responsible for receiving patients after referral/discharge , the actual implementation procedures and scope of the relevant control measures may follow the instructions of the local health department or regional commander of CDCMN after assessment.
If patients in the hospital area have urgent medical needs while the corresponding units (i.e. intensive care unit, respiratory care center, operating room, cardiac catheterization unit, radiology department, dialysis center, etc.) are located within the controlled area (with the exception of urgent or necessary medical treatment that cannot be postponed), under the principle of disease control protocol, refer/discharge patients who are in stable condition to an unaffected unit. At the meantime, reduce appointments for unaffected units and avoid transferring the patients into the controlled area.
If medical treatment within a controlled area is inevitable, the hospital shall, with the exception of emergency, submit a proposal to the local health department, regarding infection control measures such as workplace management, schedule, disinfection procedure, and location of the inpatient ward (if a disease cluster happened in the requisite unit, relevant environmental inspection plan and test results after the disinfection procedure, should be submitted along with the proposal). The local health department or regional commander of CDCMN shall evaluate the proposal based on actual circumstances and limitations. After receiving approval, the hospital may proceed with the transfer following the instructions from the authority.
3. Patients should be discharged or referred/transferred to a unaffected unit as soon as possible, depending on the clinical condition while following disease control protocol. The discharged/transferred patients are advised to practice self-health management for 14 days from the day after discharge/transfer (listed contacts should also comply with the regulations of home isolation). If suspending patient transfer from a non-disease-cluster unit are necessary, the actual scope of the suspension will be determined by the local health department or regional commander of CDCMN after evaluating current status of the outbreak, patient condition, and the actual admission capability of the referral hospital, etc.
4. If more than 2 contacts/risk targets were tested positive when related to a particular confirmed case, all risk targets should be managed as contacts; the non-contact/low risk targets shall be managed based on instructions from the local health department after evaluating the outbreak and exposure risk.
5. When symptoms occur during home isolation or during self-health management.
6. If more than 2 contacts/risk targets were tested positive when related to a particular confirmed case, all risk targets should be managed as contacts, i.e. home isolation is mandatory. This mandatory isolation may result in manpower shortage as staffs are included in this protocol, the affected unit may require substitutes to maintain basic clinical care before all patients had been transferred.
7. If the affected unit has any new suspected case within 14 days prior to the control period, all transfer/discharge/referral should be suspended until the test result has been confirmed. If there are more than 1 new suspected cases, in addition to suspending referral/transfer, the local health department should be notified to conduct epidemiological investigation and relevant examination as soon as possible and formulate a response plan.
8. In between extended intensive hospital-wide monitoring period and the control period. All affected staffs should take leave and practice self-health management until the test result has been confirmed. All staffs should abide by the regulations in "COVID-19 Expanded Screening and Case Handling Procedures for Health Care Workers" and "COVID-19 Expanded Screening Return Guidelines for Health Care Workers" protocol.
9. According to "Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases ", expanded testing should be proceed only when the contacts of the confirmed case were tested positive. However, in response to a potential outbreak, it is recommended that when a new confirmed case is reported in a different unit, all contacts and relevant risk subjects should be tested as part of the expanded inspection procedure. A contact will be determined through the epidemiological investigation conducted by the local health department. Non-contact risk group subject, e.g. staff without suspicious symptoms may can continue to work as usual.
10. The local health department shall evaluate the current status of the outbreak and the risk of exposure to provide further instructions in managing non-contact or low risk groups.
11. When there is any new positive cases in the expanded testing and inspection, the corresponding unit is determined as a disease clustering unit and the relevant recommended measures should be executed.
Table 3: Recommended control measures for units with high return-visit frequency1 in the control area during the control period of nosocomial COVID-19 clustering event.
| Unit type and Scenario | Management of New Suspected Patients | Expanded Testing and Inspection2,3 | Patient referral3,4 | Disinfection after lockdown3 | ||||
|---|---|---|---|---|---|---|---|---|
| Patient | Staff | Situation | Targets | Timing of referral | Targets | |||
| Disease cluster unit5 | Contacts6 / Risk group6 handle as reported cases | Contacts6 / Risk group6 handle as reported cases | When ≥1 confirmed case among tested contacts | Risk group | Contact / risk group were tested negative | Tested contactor / Risk group | Yes | |
| Non-disease-cluster unit | Scenario A | N/A | N/A | N/A | N/A | Refer ASAP | All patients | No |
| Scenario B8 | According to "Program of community-based surveillance" | According to "Advance Intrahospital Disease Control protocol" 9 | Suspected case tested negative | None | Suspected case tested negative | All patients | No12 | |
| Suspected case tested positive | Risk group10 | Contact / risk group were tested negative | Contact / Risk group11 | |||||
NA: not applicable, PPE: personal protective equipment, scenario A: no new suspected cases among patients or healthcare workers within the first 14 days of the control period, scenario B: new suspected cases among patients or healthcare workers within the first 14 days of the control period.
1. >50% of patients in the unit have a frequency of return-visit more than 3 times per week, e.g., hemodialysis unit, regular rehabilitation units, etc.
If patients in the hospital area have urgent medical needs while corresponding units (i.e. intensive care unit, respiratory care center, operating room, cardiac catheterization unit, radiology department, dialysis center, etc.) are located within the controlled area (with the exception of urgent or necessary medical treatment that cannot be postponed), under the principle of disease control protocol, refer/discharge patients who are in stable condition to an unaffected unit. At the meantime, reduce appointments for unaffected units and avoid transferring the patients into the controlled area. If medical treatment within a controlled area is inevitable, the hospital shall, with the exception of emergency, submit a proposal to the local health department, regarding infection control measures such as workplace management, schedule, disinfection procedure, and location of the inpatient ward (if a disease cluster happened in the requisite unit, relevant environmental inspection plan and test results after the disinfection procedure, should be submitted along with the proposal). The local health department or regional commander of CDCMN shall evaluate the proposal based on actual circumstances and limitations. After receiving approval, the hospital may proceed with the transfer following the instructions from the authority.
2. Hospitals are responsible of expanded testing and inspection of risk targets from a high-return-visit-frequency unit. The hospital should also submit the list of related personnel to local health department for follow-up management during a disease control period, as these patients may not return to the affected hospital for the routine medical treatment. The local health department shall assist subsequent referral for these patients accordingly. If these patients had been admitted to a different hospital for any reason, local health department should be notified immediately to inform the receiving hospital of the exposure history of the patient.
3. If multiple disease clusters were confirmed within the hospital, corresponding response protocol may be amended accordingly by the regional commander CDCMN or by local health department. Actual circumstances and factors should be taken into consideration, including, but not limited to, ward capacity, division quarantine, size of the district, clinical conditions of individual patient, capacity of referral hospital.
4. Patients should be discharged or referred/transferred to an unaffected unit as soon as possible, depending on the clinical condition while following disease control protocol. The discharged/transferred patients are advised to practice self-health management for 14 days from the day after discharge/transfer (listed contacts should also comply with the regulations of home isolation). If suspending patient transfer from a non-disease-cluster unit are necessary, the actual scope of the suspension will be determined by the local health department or regional commander of CDCMN after evaluating current status of the outbreak, patient condition, and the actual admission capability of the referral hospital, etc.
5. If ≥2 contacts/risk targets were tested positive when related to a particular confirmed case, all risk targets should be managed as contacts; the non-contact/low risk targets shall be managed based on instructions from the local health department after evaluating the outbreak and exposure risk.
6. When symptoms occur during home isolation or during self-health management.
7. If ≥ 2 contacts/risk targets were tested positive when related to a particular confirmed case, all risk targets should be managed as contacts, i.e. home isolation is mandatory. This mandatory isolation may result in manpower shortage as staffs are included in this protocol, the affected unit may require substitutes to maintain basic clinical care before all patients had been transferred.
If no suitable substitutes was available due to the properties of the unit (i.e. required specific skills like resource center, dialysis center, accounting office, IT department, etc.) while the affected unit was crucial for daily operation of the hospital, staff from the affected unit may return to work under instruction of regional commander of CDCMN or local health department, if they had been tested negative or show no symptom of the disease.
8. If the affected unit has any new suspected case within 14 days prior to the control period, all transfer/discharge/referral should be suspended until the test result has been confirmed. If there are more than 1 new suspected cases, in addition to suspending referral/transfer, the local health department should be notified to conduct epidemiological investigation and relevant examination as soon as possible and formulate a response plan.
9. In between extended intensive hospital-wide monitoring period and the control period. All affected staffs should take leave and practice self-health management until the test result has been confirmed. All staffs should abide by the regulations in "COVID-19 Expanded Screening and Case Handling Procedures for Health Care Workers" and "COVID-19 Expanded Screening Return Guidelines for Health Care Workers" protocol.
10. According to "Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases ", expanded testing should be proceed only when the contacts of the confirmed case were tested positive. However, in response to a potential outbreak, it is recommended that when a new confirmed case is reported in a different unit, all contacts and relevant risk subjects should be tested as part of the expanded inspection procedure. A contact will be determined through the epidemiological investigation conducted by the local health department. Non-contact risk group subject, e.g. staff without suspicious symptoms may can continue to work as usual.
11. The local health department shall evaluate the current status of the outbreak and the risk of exposure to provide further instructions in managing non-contact or low risk groups.
12. When there is any new positive cases in the expanded testing and inspection, the corresponding unit is determined as a disease clustering unit and the relevant recommended measures should be executed.
Table 4: Proposed Control Measures for Other Units1 in the Control Area during the control period of nosocomial COVID-19 clustering event.
| Unit type and Scenario | Management of New Suspected Patients | Expanded Testing and Inspection1,2 | Patient referral2,3 | Disinfection after lockdown3 | Backup required | ||||
|---|---|---|---|---|---|---|---|---|---|
| Patient | Staff | Situation | Targets | Timing of referral | Targets | Yes / No | Situation where PPE protocol should be compatible to confirmed cases | ||
| Disease cluster unit5 |
contacts6 / Risk group6:
1. Return-visiting patients7: depends8 whether to handle cases according to "Program of community-based surveillance" or reported patients. 2. For already hospitalized cases, manage accordingly by the COVID-19 reporting protocols. |
Contacts6 / Risk group6 handle as reported cases | When ≥1 confirmed case among tested contacts | Staff who are classified as a risk group | Refer ASAP | No new suspected case | Yes | Yes9 | Before completing the environmental cleaning and disinfection of the unit |
| When the patient is tested negative | Those who report for inspection according to "Program of community-based surveillance" | ||||||||
| When isolation ended | Reported cases | Before the patient is released from isolation | |||||||
PPE: personal protective equipment
1. >50% of patients in the unit have a frequency of return-visit more than 3 times per week, e.g., hemodialysis unit, regular rehabilitation units, etc.If patients in the hospital area have urgent medical needs while corresponding units (i.e. intensive care unit, respiratory care center, operating room, cardiac catheterization unit, radiology department, dialysis center, etc.) are located within the controlled area (with the exception of urgent or necessary medical treatment that cannot be postponed), under the principle of disease control protocol, refer/discharge patients who are in stable condition to an unaffected unit. At the meantime, reduce appointments for unaffected units and avoid transferring the patients into the controlled area. If medical treatment within a controlled area is inevitable, the hospital shall, with the exception of emergency, submit a proposal to the local health department, regarding infection control measures such as workplace management, schedule, disinfection procedure, and location of the inpatient ward (if a disease cluster happened in the requisite unit, relevant environmental inspection plan and test results after the disinfection procedure, should be submitted along with the proposal). The local health department or regional commander of CDCMN shall evaluate the proposal based on actual circumstances and limitations. After receiving approval, the hospital may proceed with the transfer following the instructions from the authority.
2. Other units are considered as low risk group, in which only the stationed staff (who have worked at least one 8-hour shift) should be included in the expanded inspection protocol. However, list of patients who are considered risk targets should be prepared for any further instruction from the local health department.
3. If multiple disease clusters were confirmed within the hospital, corresponding response protocol may be amended accordingly by the regional commander CDCMN or by local health department. Actual circumstances and factors should be taken into consideration, including, but not limited to, ward capacity, division quarantine, size of the district, clinical conditions of individual patient, capacity of referral hospital.
4. The hospital should refer patients with major or special medical needs (e.g. tumor removal surgery, chemotherapy, special drug application, etc.) and patients in chronic hemodialysis center (c,d,f) to unaffected hospital or units for further treatment. The discharged/transferred patients are advised to practice self-health management for 14 days from the day after discharge/transfer (listed contacts should also comply with the regulations of home isolation). For other patients without major or special medical needs, the hospital may decide whether to facilitate a referral accordingly.
5. If ≥3 contacts/risk targets were tested positive when related to a particular confirmed case, all risk targets (including staff) should be managed as contacts; the non-contact/low risk targets shall be managed based on instructions from the local health department after evaluating the outbreak and exposure risk.
6. When symptoms occur during home isolation or during self-health management.
7. Under any circumstances (i.e., when arranging a referral), a patient who has not return for treatment had developed suspected symptoms during the control period, the local health department should be notified for a follow up investigation.
8. Infection control team of the hospital and the physician shall determine further response plan after conducting epidemiological investigation and assessing the clinical condition of the patient.
9. If ≥ 3 contacts/risk targets were tested positive when related to a particular confirmed case, all risk targets should be managed as contacts, i.e. home isolation is mandatory. This mandatory isolation may result in manpower shortage as staffs are included in this protocol, the affected unit may require substitutes to maintain basic clinical care before all patients had been transferred.
If no suitable substitutes was available due to the properties of the unit (i.e. required specific skills like laundry department, dialysis center, clinical laboratory, etc.) while the affected unit was crucial for daily operation of the hospital, staff from the affected unit may return to work under instruction of regional commander of CDCMN or local health department, if they had been tested negative or show no symptom of the disease.
Table 5: Proposed Control Measures for Other Units1 in the Control Area during the control period of nosocomial COVID-19 non-clustering event.
| Scenario of the Unit | Management of New Suspected Patients | Expanded Testing and Inspection2,3 | Patient referral3,4 | |||
|---|---|---|---|---|---|---|
| Patient | Staff | Situation | Targets | Timing of referral | Targets | |
| Scenario A | N/A | N/A | N/A | N/A | Refer ASAP | All patients |
| Scenario B | Return-visiting5 or currently hospitalized patients: depends whether to handle cases according to "Program of community-based surveillance" or reported patients after evaluation6. | According to "Advance Intrahospital Disease Control protocol" 7 | Positive for those with symptoms | Staffs who are classified as a risk group8 | Refer ASAP | Asymptomatic / not suspected / not tested |
| When the patient is tested negative | Those who report for inspection according to "Program of community-based surveillance" | |||||
| When isolation ended | Reported cases | |||||
NA: not applicable, PPE: personal protective equipment, scenario A: no new suspected cases among patients or healthcare workers within the first 14 days of the control period, scenario B: new suspected cases among patients or healthcare workers within the first 14 days of the control period.
If patients in the hospital area have urgent medical needs while corresponding units (i.e. intensive care unit, respiratory care center, operating room, cardiac catheterization unit, radiology department, dialysis center, etc.) are located within the controlled area (with the exception of urgent or necessary medical treatment that cannot be postponed), under the principle of disease control protocol, refer/discharge patients who are in stable condition to an unaffected unit. At the meantime, reduce appointments for unaffected units and avoid transferring the patients into the controlled area. If medical treatment within a controlled area is inevitable, the hospital shall, with the exception of emergency, submit a proposal to the local health department, regarding infection control measures such as workplace management, schedule, disinfection procedure, and location of the inpatient ward (if a disease cluster happened in the requisite unit, relevant environmental inspection plan and test results after the disinfection procedure, should be submitted along with the proposal). The local health department or regional commander of CDCMN shall evaluate the proposal based on actual circumstances and limitations. After receiving approval, the hospital may proceed with the transfer following the instructions from the authority.
2. Other units are considered as low risk group, in which only the stationed staff (who have worked at least one 8-hour shift) should be included in the expanded inspection protocol. However, list of patients who are considered risk targets should be prepared for any further instruction from the local health department.
3. If multiple disease clusters were confirmed within the hospital, corresponding response protocol may be amended accordingly by the regional commander CDCMN or by local health department. Actual circumstances and factors should be taken into consideration, including, but not limited to, ward capacity, division quarantine, size of the district, clinical conditions of individual patient, capacity of referral hospital.
4. For patients with major or special medical needs (e.g. tumor resection, chemotherapy, special medication application, etc.), the hospital should give priority to facilitating referrals to other hospitals or to units in non-restricted areas of the hospital. The transferred patients are advised to practice self-health management for 14 days from the day after discharge/transfer (listed contacts should also comply with the regulations of home isolation). For other patients without major or special medical needs, the hospital may decide whether to facilitate a referral accordingly.
5. Under any circumstances (i.e., when arranging a referral), a patient who has not return for treatment had developed suspected symptoms during the control period, the local health department should be notified for a follow up investigation.
6. Infection control team of the hospital and the physician shall determine further response plan after conducting epidemiological investigation and assessing the clinical condition of the patient.
7. In between extended intensive hospital-wide monitoring period and the control period. All affected staffs should take leave and practice self-health management until the test result has been confirmed. All staffs should abide by the regulations in "COVID-19 Expanded Screening and Case Handling Procedures for Health Care Workers" and "COVID-19 Expanded Screening Return Guidelines for Health Care Workers" protocol.
8. According to "Contingency recommendations for hospitals in response to COVID-19 (Wuhan pneumonia) confirmed cases ", expanded testing should be proceed only when the contacts of the confirmed case were tested positive. However, in response to a potential outbreak, it is recommended that when a new confirmed case is reported in a different unit, all contacts and relevant risk subjects should be tested as part of the expanded inspection procedure. A contact will be determined through the epidemiological investigation conducted by the local health department. Non-contact risk group subject, e.g. staff without suspicious symptoms may can continue to work as usual.
9. When there is any new positive cases in the expanded testing and inspection, the corresponding unit is determined as a disease clustering unit and the relevant recommended measures should be executed.
¶ Contributions
Translation Associate Editor(s)
Li-Tien Hsu
Translators
Fu-Hsiang Chen, Pin-Yan Kuo, Chih-Chi Su, Chang-Zhang Chai, Te-Wei Hsieh, Chi-Ching Huang, Shang-Chen Yang, Dai-Yun Lee
Typographers
Yi-Yun Cheng, Yao-Chung Chang