Facilities Management and Operations

Facility LayoutCopy Link!

Literature Review (Hospital Operations): Gallery View, Grid View

Principles for Adapting Spaces for COVID-19Copy Link!

Updated Date: December 19, 2020

Designating COVID Care Areas: Where possible hospitals and clinics should establish designated areas for screening, triage, specimen collection, and COVID inpatient care. It is important to try to separate patients by how likely they are to have COVID to avoid putting patients who do not have COVID on wards or in waiting areas where they could contract it. Patients who have tested negative or who are not suspected to have COVID-19 should never be co-housed with COVID positive or patients under investigation (PUI) for COVID infection.

  • Distances between people should be at least 1 meter (WHO recommendation), and ideally 2 meters (CDC recommendation) in all contexts.
  • Using outdoor spaces and spaces with good filtration or air turnover can decrease risk. All indoor spaces should be sufficiently ventilated and COVID care areas should be negative pressure whenever possible.
  • Areas should be clearly marked with appropriate and standardized signage indicating the category of precaution and PPE that is required to enter.

Entrances, Screening and Testing AreasCopy Link!

Updated date: December 19, 2020

Entrances and Screening AreasCopy Link!

To ensure all persons entering a healthcare facility are screened for symptoms of COVID-19, most facilities have reduced the number of entrances and exits (see Screening and Triage). Infrastructure adaptations include:

  1. Designating separate entrances for healthcare workers and patients. This allows for all staff to pass through the same entrance and undergo active syndromic surveillance (WHO).
  2. Ensuring screening areas are open to air (e.g. vehicle pull ups or on walkway outside). If weather or infrastructure make this impossible, people should never need to cluster close together while waiting to be screened.

Waiting AreasCopy Link!

After screening positive, individuals should be directed to a waiting area for Acuity Triage. Within the waiting area for those who screen positive, patients must be able to remain 2 meters from any other patient, or have physical barriers in between. The waiting room should be clearly visible from the triage area.

Specimen Collection AreasCopy Link!

Updated Date:

  1. COVID respiratory sample testing and sputum collection should be done outside in an area designated for sample collection where possible. Some places use outdoor stands, tents, and drive-throughs.
  2. If respiratory sampling must be done indoors, ensure adequate PPE and air turnover/filtration where available.
  3. Blood finger pricks and blood draws can be done in the consultative space.

Open Shared WardsCopy Link!

Updated Date: December 19, 2020

Ward DesignCopy Link!

In settings where private rooms are not feasible, patients with confirmed and suspect COVID are admitted to open wards, ideally stratified by likelihood of disease (see Case Definitions and Isolation).

Finding space: To create these new wards, some healthcare settings combine or convert wards typically used for other reasons into COVID-19 treatment wards

Designs for open shared wards: for COVID care should ensure that there are donning and doffing areas at the entrance to the ward, separate staff work and break areas, supply areas within the ward, and separate bathrooms for patients and staff. There should be sufficient spacing between patient beds to maintain physical distancing (minimum 1 meter, or 2 meters if health care workers will move between beds). Screen walls/ partitions between beds in open wards should be used to reduce particle transfer between patients.

Grouping by risk level: Ideally, separate wards will be created by Likelihood of COVID Disease. If separate wards are impossible, patients may be cohorted within different areas of the same ward, grouped according to likelihood level. Use physical distance (>2m) or barriers (designs available in the BHI guidelines below) between groups to minimize risk to PUI patients under investigation who do not have COVID (for detailed information on barriers see BHI Infrastructure Tool below). Strict decontamination and other Facility-based IPC Practices must be performed between patients, and practitioners should see patients from the lowest to the highest likelihood areas.

Tool: COVID Ward Plans Developed by PIH and Build Health International (BHI)
Tool:
BHI Infrastructure Guidelines
Tool: Ward Design Troubleshooting

Critical Care Units: Care of critically ill patients should ideally take place in intensive care wards or units, high dependency units (HDU) (designated units with increased personnel, equipment, and monitoring capacity), or in a designated high-dependency area of a larger ward with adequate resources to care for acute patients. Separate wards (and/or separate negative pressure rooms with donning/doffing antichambers) are particularly important for critical care activities to reduce the risk of aerosol spread as aerosols are generated from some critical care activities such as intubation and nebulization (see Aerosol Generating Procedures).

BathroomsCopy Link!

Wards should have dedicated separate bathrooms for suspected and confirmed COVID-19 patients.

Staff Work AreasCopy Link!

Wards should have designated staff work areas. In open wards, work areas near patient beds should be considered potentially dirty, and staff should remain in PPE in these areas. For many environments it may help to designate clean staff areas in nearby rooms where staff can take breaks.

Donning and Doffing StationsCopy Link!

At each patient room or in each ward, there should be a donning area separated from patients where healthcare workers can put on protective gear. There should also be doffing stations for each area where PPE can be removed. Buckets and bins for used material should separate material that will be decontaminated (such as goggles), incinerated (such as cloves), or laundered (such as reusable gowns and linens). Dirty material should be handled with appropriate PPE

Ventilation and FiltrationCopy Link!

This section is in process

Infrastructure Standards (Resource-Limited Settings)Copy Link!

Updated Date: December 19, 2020

The table below summarizes suggested basic facility needs and standards in resource-limited settings in relation to water supply, power supply, power distribution/lighting, wastewater treatment, hazardous waste, oxygen, ventilation, internet connectivity, and fire safety. Each situation and site is unique, and this should be taken as suggested guidance and adapted to local needs, regulations, and resources.

Facility Needs

COVID-19 Treatment Center Standards

Water Supply

1. Supply

2. Potability

3. Reserve Capacity

4. Redundancy

5. Access Points

Adequate water supply is required for laundry, hand washing, cleaning, patient bathing, and drinking water for patients, staff, and family caregivers.

Water should be tested for pathogens and then treated as required to make it potable. One common disinfection method is to treat it with chlorine, in which case the water should be tested for residual chlorine to maintain levels between 0.5 and 2 ppm. See WHO and CDC guidelines for more details. (WHO, CDC)

Power Supply

1. Reliability

2. Capacity

3. Redundancy

4. Controls

Consistent electrical power is needed for safe basic care. For non-ICU level care, two reliable sources of electricity are needed. They can be any combination of diesel generator, solar and batteries, or utility grid connection. In cases where diesel generators are the only source of electricity, one primary generator and two backup generators are recommended for redundancy. Whatever the energy sources are, they should include an automatic transfer switch between the two primary sources of power. If there is an ICU, we recommend that there be a UPS with a size of at least 20kVAto feed the receptacles and lights for the space. Main circuit breakers and electrical panels should be readily accessible but located outside of patient areas so that a technician can service without PPE. Generators should be equipped with an automatic start signal fed from the automatic transfer switch. Generators should also have an external fuel tank. This fuel tank should be sized to provide fuel for a minimum of seven days continuous generator use.

Power Distribution and Lighting

1. Ward level

2. Distribution level

3. Documentation

Treatment and administrative areas need a minimum of 40 foot-candles of illumination at 1 meter above the floor. All lighting should be LED strip lighting securely hung on chain or wire at a minimum of 2.6 meters above the floor. All treatment areas should have a minimum of two duplex receptacles for each bed or patient exam chair. There should be no more than five duplex receptacles on each 20 amp circuit breaker. For ICU, there should be three dedicated 20 amp duplex receptacles for each bed all fed from uninterruptible power supply (UPS).

Wastewater Treatment

1. Treatment Level

2. Capacity

3. Monitoring and Maintenance

Wastewater can be treated in many different ways (See Compendium of Sanitation Systems and Technologies), and care must be taken to prevent the contamination of groundwater and water sources. One common, simple treatment method is a septic tank and leach field. In this case wastewater from hand sinks, janitorial sinks, toilets, and showers would be discharged by gravity into a holding tank sized based on flow requirements for a 48-hour retention time, and then discharged into a soak pit or leaching field, built to WHO and MSF Guidelines. Toilets in temporary facilities should be dedicated pit latrines which discharge into a lined tight tank of sufficient size to require pumping no more than twice per month. The lined pit latrine should have access and inspection hatches and be vented to promote breakdown of solids (see: World Bank Guidelines for Ventilated Improved Pit Latrines). There should be an overflow pipe for liquid wastewater at least 15 cm below the floor running to a separate soak pit.

Biohazardous, Pharmaceutical, and Chemical Waste

1. Collection and Sorting

2. Disposal

3. Staff Safety

Sharps containers should be mounted at between 1.3 to 1.4 meters above the floor. The container should be placed in a visible location, within easy horizontal reach, and below eye level. The container should also be placed away from any obstructed areas, such as near doors, under sinks, near light switches, etc. Containers should be clearly visible to the health care worker. There should be one 5-liter sharps container for every 4 beds or patient exam stations, and no less than 1 sharps container per room. The collection, storage and disposal of unwanted pharmaceutical and chemical waste should also be considered. (See WHO’s Safe Management of Wastes from Health-Care Activities)

Ventilation

Either mechanical ventilation through the use of exterior exhaust fans and opposite wall/end air intake louvers to achieve 12 air changes/hour (ACH) by volume in the space. It may be possible in some locations and climates to achieve 12 ACH in a ward by using natural ventilation especially a scheme that utilizes low intake and high exhaust. If this method is employed, it is strongly recommended that a professional engineer be consulted and that the space be tested for CO2 build up and transfer prior to the space being used.

If isolation rooms are desired, additional ventilation needs to be provided to meet ventilation requirements. Through-wall exhaust fans are an effective way to create negative pressure in the isolation room and to provide the recommended 12 ACH, while natural ventilation is not generally an effective method for achieving air flow in small rooms.

Oxygen

1. Supply

2. Distribution

3. Reserve Capacity

4. Redundancy

Anticipate that up to 40% of patients with COVID-19 will require O2.

An oxygen quantity of 10 liters per minute (LPM) per bed is recommended for sizing piped oxygen planning. RESERVE oxygen is required as well as REDUNDANT CAPACITY if the primary supply fails. If a manifold with high pressure oxygen cylinders is used, then there should be an adequate supply for all the beds for 24 hours of use at 6 liters per minute. In a 16-bed ward this would translate to 96 LPM. A 0.75 demand factor then can be applied so the 24-hour supply would be 96 LPM x 60 minutes x 0.75= 4320 liters per hour. An H-cylinder yields approximately 7,000 usable liters; so, for a 24 hour supply you would need 15 full cylinders. A reserve manifold (in addition to the 15 cylinders) should have a minimum of 4 full H-cylinders. The manifold and zone valve must be connected to an audible (and if possible) visual alarm to notify if there is a drop in oxygen pressure below 40 PSI. Redundancy in O2 means having a second oxygen source if the first one fails. For example, bedside O2 concentrators could be a redundant oxygen for a cylinder based system run out.

Network/Internet Connectivity

1. Reliability

2. Speed

3. Availability

Ability to connect to the internet (via wire or wireless connection) wherever layout of the facility deems necessary. Suggest: Dual Wired RJ45 connections at each convenient and/or required location. Wireless Access Points placed throughout the facility positioned for complete and optimum coverage. Consider backup internet source from 4G cellular routers, if available.

Fire Safety

1. Fire Extinguisher

2. Smoke Detectors

3. Fire Assembly Points

4. Fire Evacuation Plan

Fire safety is especially important in buildings where a high volume of compressed oxygen is stored and used. Fire safety in temporary facilities in countries with little or no fire safety training and standards is always challenging. We suggest a flexible commonsense approach. Within the temporary wards, try to avoid using sheets or other linens for shading as these are a fire hazard. Fire extinguishers should be hung on the walls in locations that are accessible and highly visible. We recommend a minimum of two per every 1000 square feet, plus one by each exit and entrance. There should be fire extinguishers not more than 50 feet (or 15 meters) apart throughout the facility. The fire extinguishers should be clearly marked with a sign and arrow in the appropriate language.

Visitation PoliciesCopy Link!

Updated Date: September 24, 2020
Literature Review:
Gallery View, Grid View

When community rates of COVID are high, institutions may need to restrict visitors from entering health facilities. This protects visitors, patients and staff from unnecessary exposure, and facilitates safe physical distancing within the facility. Visitor policies should define 1) how visitors are screened and what PPE they must wear, 2) who can visit and under what circumstances, 3) any restrictions on visitor movement within the facility, and 4) any exceptions to the policies.

General principles for visitor policies:

  1. COVID-19 positive or PUI inpatients should not be are not allowed any visitors unless absolutely necessary. Institutional policies should specify what circumstances exceptions should be made in.
  2. Visitors must stay in the room for the duration of the visit.
  3. In most cases, only one visitor is allowed per day.
  4. No children under the age of 16 may visit.
  5. Visitors must wash hands, and follow universal face covering guidelines, and pass COVID symptom screening.

Examples of Possible Visitor Exceptions (must be adapted to each individual facility and epidemiologic circumstance):

  1. Adult outpatients are not allowed visitors unless they have a medical need for 1 assistant or guardian. Providing a letter stating medical need at the time of visit is recommended.
  2. Patients who are under the age of 18 may have one parents or guardian visitor. If facility circumstances allow, both parents/guardians should be allowed to visit.
  3. Patients with disruptive behavior may be visited by 1 person important to their care.
  4. Patients who have altered mental status or developmental delays may have 1 caregiver visit to increase their safety.
  5. Patients who receive home care may have 1 person visit to receive care-related education or training.
  6. Patients giving birth may have 1 partner and 1 other support person (up to 2 visitors)
  7. Patients on the Nursery/Neonatal Care Unit may have 1 partner and 1 other support person.
  8. Patients who are at end-of-life may have two 2 visitors.
  9. Patients undergoing surgery or procedures may have 1 visitor. Visitor must leave as soon as possible after the procedure/surgery.

In many countries, family members play a significant role in the daily care of inpatients. If visitors cannot be safely allowed during periods of high community transmission, facilities should plan for additional support staff to help patients meet their routine activities of daily living, including personal hygiene and feeding/nutritional needs.

Tool: Current BWH Visitation Policies

Surge PlanningCopy Link!

Updated Date: September, 2020

Stages of CrisisCopy Link!

Literature Review (Ethics): Gallery View, Grid View

During a COVID outbreak, growing patient numbers (known as a surge) can outpace hospital capacity, requiring adjustments to operations. Healthcare facilities should plan for sequential adjustments to operating procedures in order to meet capacity needs as safely as possible over the course of the crisis. Many healthcare organizations plan ahead for multiple stages of a surge, developing plans for patient care and management of resources.

Preparation and planning for surge events requires establishing an incident management committee, establishing and training triage teams, and assessing resources and systems in order to provide the best possible response to increasing patient numbers and changes in severity of illness in the patient population. Crisis situations present new requirements for infection control as well as new ethical challenges.

Conventional

Contingency

Crisis

Space

Usual patient care space maximized

Patient care areas repurposed (PACU, monitored units for critical care)

Non-traditional areas used for critical care or facility damage does not permit usual critical care

Staff

Additional staff called in as needed

Staff extension (supervision of larger number of patients, changes in responsibilities, documentation, etc)

Insufficient ICU trained staff available/unavailable to care for volume of patients, care team model required & expanded scope

Supplies

Cached/on-hand supplies

Conservation, adaptation and substitution of supplies with selected re-use of supplies when safe

Critical supplies lacking, possible allocation/reallocation or lifesaving resources

Standard of care

Usual care

Minimal impact on usual patient care practices

Not consistent with usual standards of care (Mass Critical Care)

ICU expansion goal

1.2x usual capacity (20% increase)

2x usual capacity (100% increase)

3x usual capacity (200% increase)

Resources

Local

Regional/State

National

Source: Christian et al. 2014

Planning for Pandemic DemandsCopy Link!

Updated Date: September, 2020

Incident Management CommitteeCopy Link!

Hospitals will ideally already have an established incident command structure for responding to crises. If a structure is not already established, an ad hoc structure can be created. The incident management committee should systematically estimate maximum total demand and assess maximum total capacity, including space, supplies, and staff. Resource data should be updated regularly and made as transparent and accessible as possible to all staff.

The Incident Management Committee should be formed of members across a wide range of facility services and departments. Members of the Committee should be leaders who can actively implement committee decisions. Committee members will be more effective if they consult and collaborate with the staff in their departments who perform direct tasks (for example, disinfection and bedside nursing care).

Recommended Membership of Incident Management Committee:

  1. Administration
  2. Communication
  3. Medical personnel
  4. Nursing administration
  5. Bedside nursing team clinical leaders
  6. Infection control
  7. Respiratory therapy
  8. Human Resources
  9. Security
  10. Pharmacy
  11. Laboratory
  12. Maintenance and engineering
  13. Dietary services
  14. Laundry, cleaning, and waste management

Reorganizing Services to Increase Hospital CapacityCopy Link!

Reorganization of services may be necessary to increase hospital capacity in surge situations. However, this can have unintended consequences for the health of populations; these consequences can increase over time. Each strategy should be continuously re-evaluated for its impact and ongoing necessity.

  1. Anticipate and plan for increasing patient numbers and changes in location of admissions.
  1. Identify which services must be maintained at all times; consider prioritizing services and temporarily stopping some services if necessary.
  2. Cancel elective (non-urgent) procedures and surgeries at least 1 week prior to the expected surge to free inpatient beds used for post-operative care.
  3. Whenever possible, shift to remote services, home visits, and home medication delivery.
  4. Minimize the number of people accompanying patients.
  5. Modify outpatient services as described below (see Adapting Outpatient Services).
  6. Organize appointment schedules and seating to ensure physical distancing.
  7. Reassure patients that routine care is available, as data show decreases in health service availability (WHO) and utilization (Czeisler et al) during the pandemic.
  8. Shift non-COVID inpatients to alternate treatment sites. For example:
  1. Shift malnutrition treatment to health centers or local community settings.
  2. Transition patients on long courses of antibiotics to oral antibiotics and discharge home.
  3. Move all routine hospital outpatient visits (antenatal care, children under age 5) to primary care centers and repurpose outpatient space for inpatient care.
  4. Identify alternative treatment sites for mild cases (churches, hotels, schools, etc.) and work to establish them with local authorities.

StaffingCopy Link!

  1. Plan for staffing interruptions, increased patient acuity, and need for additional staff. Anticipate a possible increase in staff illnesses and exposures.
  2. Analyze staff skills to develop plans for staff redeployment to meet gaps caused by increasing demand or staffing interruptions due to staff illness or quarantine.
  3. Consider training or rapid capacity building to allow staff to redeploy if needed.
  1. Plan to meet staffing needs as effectively as possible in the event of a contingency or crisis situation.
  1. Consider ways to reduce staff exposure by combining tasks sometimes done by different cadres or workers to limit entry and exit to COVID care spaces (for example, have a nurse take routine vital signs while administering a medication, even if routine vitals are normally taken by an aide).
  2. Review existing occupational health systems and plan for increased occupational illnesses in order to maintain a healthy workforce. Develop standardized staff screening for COVID symptoms and establish systems for follow-up and testing.
  3. Make it clear to all that team members should not be asked to assume added risk for the explicit purpose of minimizing someone else’s exposure (for example, a physician should not ask a nurse to enter an isolation room solely to facilitate a phone call between the doctor and the patient).

Adapting Outpatient Health ServicesCopy Link!

Community level

  1. Ensure visiting health professionals, community health workers and traditional healers have adequate PPE.
  2. For stable patients, work with the pharmacy team to obtain extended medication supplies to prevent unnecessary facility visits. Also consider decentralized pharmacy pick-up points.
  3. Create lists of high-risk patients to provide remote care, safety plans, and no disruptions to medication supply.
  4. Recruit community health workers, visiting nurses, and other team members to distribute medication refills and check on high-risk patients (determine and deliver an essential social support package).
  5. Maintain physical distancing and universal face covering guidelines according to local policies. Additional measures to enable social distancing include: additional make-shift clinic space (e.g., tents) and weekend clinics.
  6. For routine follow-up of chronic patients, try to extend periods between visits where possible; If relevant, address medication, testing, home visits, and other needs as described previously.

Remote Services and SupervisionCopy Link!

  1. Determine the best and most accessible platform for remote services, considering costs and network reliability.
  2. Utilize private, secure, and appropriate channels of communication.
  3. Establish referral pathways with supervisors for those with severe psychological distress.
  4. Allocate resources for air time to ensure staff and patients connect through phone and video calls.
  5. Define clear times when providers will be available for sessions.
  6. When clinical supervision is part of normal care, schedule times for regular clinical supervision with staff.

Crisis Standard of CareCopy Link!

Updated Date: September, 2020
Literature Review (Resource Allocation):
Gallery View, Grid View

Literature Review (Triage): Gallery View, Grid View

In the event of a patient surge, allocation of advanced care services may become necessary for treatments such as oxygen therapy or ventilation.

  1. A “crisis standard of care” is a set of principles to help guide triage of resources when there are insufficient resources to meet medical needs(including ICU beds, ventilators, dialysis machines, etc.) (Institute of Medicine 2012).
  2. A crisis standard is triggered by “a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (for example, pandemic influenza) or catastrophic (for example, earthquake, hurricane) disaster” (Institute of Medicine 2012).
  1. It must be formally declared by regional/state authorities and hospital leadership.
  2. It typically involves contingencies for different stages of a crisis.
  1. Declaring a crisis standard allows transparency in decision making, which is essential when resources are scarce and cannot be provided to all who need them (Biddison et al).
  2. Planning for these possibilities in advance is critical to ensure equity and to protect individual healthcare workers from needing to make resource allocation decisions.
  3. For a comprehensive framework for critical care resource allocation, please see an Example Model Developed at the University of Pittsburgh that many institutions incorporate into their plans.

Goals and Principles when Triaging ResourcesCopy Link!

This section is in process

Principles in Triaging ResourcesCopy Link!

The following is adapted from WHO Guidance:

  1. Just, equitable, and non-discriminatory distribution of scarce resources.
  2. Transparency in protocols and decision-making, with information made accessible and understandable at an elementary-school level in all languages spoken by the patient population.
  3. Non-abandonment of patients needing care. Palliative care must be provided to all patients with respiratory failure not receiving life sustaining treatment.
  4. Duty of organizations to plan and implement equitable management of resources in advance, in order to avoid placing the burden of triage decision-making on frontline healthcare workers. Committees or triage officers who are not providing direct patient care should be designated to guide these decisions.
  5. Standardized assessment: Triage officers and or committees should have a standardized approach to using clinical data for making triage decisions. One example is the Sequential Organ Failure Assessment (SOFA) calculator.
  6. Reassessment at routine intervals: Decisions should be ongoing as clinical parameters change.

Tool: WHO Guidance on Ethics and COVID-19

Resource Triage TeamsCopy Link!

  1. Consensus guidelines suggest that all decisions about triage should be made by a Triage Officer, not the bedside clinicians caring for patients (Christian).
  2. The Triage Officer should be a physician with critical care training.
  3. Decisions about triage should be made based on protocols established by the hospital. These protocols should be evidence-based and nondiscriminatory (Gostin et al).
  4. Bedside clinicians, patients, and families should have ways for appealing (challenging) triage decisions.
  5. An oversight committee should be established to review decisions made by Triage Officers to ensure consistent application of the triage protocol and to make decisions about appeals.

Equipment AdaptationsCopy Link!

Updated Date: July, 2020

Shared Ventilators and Ventilator AlternativesCopy Link!

Literature Review (Alternative Ventilator Options): Gallery View, Grid View

Use of Anesthesia Machine for Prolonged ICU VentilationCopy Link!
  1. In the event of shortage of ICU ventilators, anesthesia machines may be used for prolonged ICU ventilation (ASA/ASPF Ventilator Guidance)
  2. A quick reference sheet and hotline to set up and monitor a repurposed anesthesia machine are provided (ASA/APSF Quick Setup Instructions)(1-800-224-1001)
  3. Draeger and GE have provided specific guidance for their anesthesia machines (GE Guidance)(Draeger Guidance)
Use of Adapted BIPAP machinesCopy Link!

This section is forthcoming

Use of Single Ventilator Multiple PatientsCopy Link!

The ASA, SCCM, APSF, AARC, AACN, and CHEST societies have issued a joint consensus statement against using a single ventilator for multiple patients (Joint Statement On Multiple Patients Single Ventilator). Splitting of ventilators comes with many risks, including infection transfer between patients, difficulty positioning essential equipment, difficulty adjusting set respiratory parameters to meet individual patients’ needs and different clinical courses, difficulty controlling for sensed parameters (e.g. spontaneous respiration), alarm failures, measurement error in ventilator self-checks, and ethical dilemmas in prioritizing different patients’ treatment plans.

Supply Chain, Logistics, and ProcurementCopy Link!

Updated Date: December 19, 2020

Supply chain, logistics and procurement are critical aspects of a COVID-19 response. In some settings, particularly resource-limited settings, supply chain systems are underdeveloped; the guidance below reflects general principles for supply chain management in an emergency setting. In addition, operations staff, including logisticians, couriers, drivers, and warehouse workers, should receive basic education about COVID-19, including modes of transmission, proper hand hygiene, and any precautions required (wiping down equipment, wearing gloves to handle boxes, wearing masks, etc.)

GovernanceCopy Link!

  1. Clearly identify a specific individual to lead emergency supply chain efforts.
  2. If applicable, implement the use of emergency procurement processes to get necessary commodities and services where needed in time. Emergency procurement processes might include simplified bid solicitation or alternate approval procedures to ensure the most efficient and fastest response.
  3. Develop protocols for how the emergency and routine supply chains should interact, including storage, information systems, and purchasing.
  1. Identify regularly stocked items whose availability may be affected by COVID due to increased demand or global shortages and plan for additional procurement. It may also be necessary to identify items that can be used as substitutes for regularly stocked items.
  2. Commonly, emergency and routine supply chains are not separated at the beginning of the response and are later separated as dedicated funding becomes available. More restrictive funders, such as bilateral agencies (USAID, DFID, etc.) will require this.
  3. Clearly identify and authorize specific funds for emergency procurement in the earliest stages of the response and identify ongoing funding approval processes. Clearly identify a specific individual to lead clinical decisions for emergency supply chain efforts, including product specifications, substitutions, and forecasting.
  4. Ensure that supply chain governance is aligned with international and national institutions.
  1. For individual institutions and/or organizations in resource limited settings, clarify country-level governance in partnership with the Ministry of Health.
  2. Determine whether the UN Logistics Cluster System (Log Cluster) has been established and identify how the organization will engage.
  1. Among other things, this global mechanism coordinates requests for supplies and transportation across local, regional, and global implementers of all sizes, including donors (e.g. USAID, DFID) and local governments. LogCluster reports contain important information on these topics.
  2. If Log Cluster is not active, identify mechanisms to coordinate efforts with other partners involved in emergency response.
  1. Often this happens through the Ministry of Health and/or the implementing partner for bilaterally or multilaterally-funded supply chain projects.

Mapping and InterventionsCopy Link!

  1. Map current supply systems and available resources in health and other sectors.
  2. If UN LogCluster has been activated, utilize their mapping, which will include local & global partners (including military, private, and public agencies).
  3. Coordinate closely with district and national Ministry of Health Colleagues to understand public supply chain processes, even if they are seemingly sparse.
  4. Review PIH’s in-country supply chain management systems to identify risks that could disrupt existing systems (i.e. importation and customs, strategic stockpiling, storage, security, transportation, distribution, information systems, and requisition processes) for clinical and other essential supplies and equipment and create contingency plans.
  5. Identify the list of items considered essential to the response, including clinical and non-clinical supplies and equipment.
  6. Conduct review of stock levels and orders already in the pipeline of all items on a facility’s formulary. Use relevant procurement mechanisms and partnerships to address low stock levels, prioritizing essential items.
  7. Conduct rapid assessment of essential clinical and non-clinical equipment/systems and spare parts (oxygen, generators, incinerators, patient monitoring equipment, etc.). Use relevant procurement mechanisms and partnerships to increase access to needed equipment and stock spare parts.
  8. Conduct rapid assessment of vehicle fleet and stocks of spare parts (SUVs, ambulances, motos, etc.) as well as access to fuel. Use relevant procurement mechanisms and partnerships to avoid disruption to transportation and distribution networks.
  9. Map existing qualified suppliers, considering countries of origin for manufacturing and suppliers’ own emergency response procedures, including ability to obtain needed quality assurance documentation and navigate the changing environment around exportation. It may be necessary to expand sourcing to include new suppliers to decrease the risk of order delays or cancellations. For all items procured, ensure suppliers can provide the required quality assurance documentation.
  10. Work with suppliers and international bodies like the Log Cluster to identify items that may be in global shortage due to increased demand caused by the pandemic, or countries of origin that may experience delays in export. Consider placing additional orders with a diverse list of qualified suppliers to avoid disruptions to supply.
  11. Assess the capacity of the local market to meet increased demand for clinical and other essential supplies. Encourage preference for qualified local sources when possible.
  12. Assess systems providing visibility into stock levels and rates of consumption. Ensure clear communication systems are in place to communicate shortages and urgent needs.
  13. Assess storage and warehousing infrastructure and capacity including for cold chain products. It may be necessary to identify additional temporary storage for the items needed for the response, such as PPE.
  14. Assess basic in-country logistics and identify any major (or potential) infrastructure breakdowns (port closures, road or bridge disruptions, etc.) and create contingency plans.
  15. Map existing or anticipated disruptions to international shipping routes. Consider identifying additional logistics providers.
  16. Work with donors to ensure in-kind donations are aligned with identified needs.
  17. Assess likely funders of medium and long-term response efforts to anticipate allowable commodities and other restrictions.

Example Supply Lists:

Items needed in different areas of COVID-19 treatment centers. In addition, see PPE for a full list of necessary PPE.

Durable Equipment

Secondary Screening Area

Presumptive COVID-19 Area

COVID-19 Ward

Critical Care Area

Scales, adult and pediatric

X

X

X

Thermometers, infrared

X

X

X

X

Pulse oximeters

X

X

X

X

Vital signs machines, blood pressure

cuffs

X

X

X

X

Cardiac monitors

X

Stethoscopes

X

X

X

X

Ultrasound

X

X

Intravenous Infusion pumps

X

Beds with washable mattress

X

X

X

Bed linens

X

X

X

Pillows (washable)

X

X

X

Plastic chairs

X

X

X

X

Waste bins

X

X

X

X

Nurse / Provider station table

X

X

X

X

Pharmacy tables

X

X

X

Pharmacy cabinet

X

X

X

Shelves

X

X

X

Medication trolley

X

X

X

Refrigerator

X

X

X

White board with markers for patient tracking

X

X

X

Laryngoscope, various sizes

X

Hemocue

X

X

X

Glucometer

X

X

X

X

Light for clinical exams

X

X

X

X

Clock with second hand

X

X

X

X

Suction machine

X

Oxygen source – O2 tanks vs O2 concentrator

X

X

X

Ventilators

X

Consumables (products and disposable items)

Secondary Screening Area

Presumptive COVID-19 Area

COVID-19 Ward

Critical Care Area

Non-sterile gloves - small

X

X

X

X

Non-sterile gloves - medium

X

X

X

X

Non-sterile gloves – large

X

X

X

X

Bar soap + water source

X

X

X

X

Hand sanitizer

X

X

X

X

Bleach/Chlorine

X

X

X

X

Biohazard bag

X

X

X

X

Sterile gloves, assorted sizes

X

IV cannulae 18 – 24 gauge

X

X

X

IV tubing, 15-20 drops/mL

X

X

X

IV tubing, 60 drops/mL

X

X

X

Nasal cannula, pediatric and adult

X

X

X

O2 masks, pediatric and adult

X

X

X

O2 masks, non-rebreather, pediatric and adult

X

X

X

Adhesive tape

X

X

X

X

Bags, Urinal drainage, with non-return valve and tap, Sterile, 85cm tube, 2000mL

X

X

X

Nasogastric tubes for adults and children

X

X

X

Foley Catheters 12Fr and 16Fr

X

X

X

Needles, 18G, 21G and 25G

X

X

X

Spacers for inhalers

X

X

X

Syringes, 5ml, 10ml and 20 ml

X

X

X

Cotton wool, 500g roll

X

X

X

Wristbands, Patient Identification

X

X

X

Body bags

X

X

X

Sharps containers, 3 gallon

X

X

X

Tablet bags, Resealable, with Pictogram, 80mm x 100mm

X

X

X

Underpads, Tissue, 3 ply, 17in x 24in (chux)

X

X

X

Bags, Specimen transport, 6in x 9in

X

X

X

Tubes, Blood collection, Heparin (Green) Vacutainer Tubes Case

X

X

X

Tubes, Blood collection, K3 EDTA (K3E), 15% solution, Lavender, 6mL

X

X

X

Tubes, Blood collection, Serum, Silicone coated, Red, 6mL

X

X

X

HIV rapid tests

X

X

X

Hemocue microcuvettes

X

X

X

Glucometer strips

X

X

X

Lancets

X

X

X

Consumables for Mechanical Ventilation (if applicable)

Secondary Screening Area

Presumptive COVID-19 Area

COVID-19 Ward

Critical Care Area

Viral filter for ventilator circuit

X

Ventilator circuit

X

Ambu bag, adult, pediatric and neonatal

X

Endotracheal tube - 4.0 - 8.0

X

Water Sanitation, Hygiene, and Waste ManagementCopy Link!

Updated Date: September 24, 2020

WaterCopy Link!

  1. Persistence of SARS-CoV-2 in drinking-water is possible.
  2. There is no evidence to date about survival of SARS-CoV-2 in water or sewage, but this virus is likely to become inactivated significantly faster than non-enveloped human enteric viruses with known waterborne transmission (such as adenoviruses, norovirus, rotavirus and hepatitis A).

Disinfection and CleaningCopy Link!

FrequencyCopy Link!

COVID-19 virus can likely survive on surfaces, for variable amounts of time (hours to a few days). Survival time can depend on the type of surface, temperature, relative humidity and specific strain of the virus. Surfaces should be cleaned periodically with soap and water, and with disinfectant. The following is a suggested guide developed by Partners In Health as an example for some settings. Individual hospitals may have different policies. Always follow your hospital’s policy.

Offices and NON-CLINICAL areas

Recommended Minimum Cleaning and Disinfecting Frequencies

Type of Surface

Examples

Clean with Soap and Water

Clean with Disinfectant*

Minimally Touched Surfaces

Floors

Ceilings

Walls

Windows

When dirty

(At least 3 times/week)

After human contact When Dirty

(At least weekly)

Frequently Touched Surfaces

Door handles

Table tops / Desks

Light switches

Computers

Sinks/basins

Daily

Daily

CLINICAL AREAS (Including Isolation Units)

Recommended Minimum Cleaning and Disinfecting Frequencies

Type of Surface

Examples

Clean with Soap and Water

Clean with Disinfectant*

Minimally Touched Surfaces

Floors

Ceilings

Walls

Blinds

3 times daily + any known COVID-19 exposure

3 times daily + any known COVID-19 exposure

Frequently Touched Surfaces

Door handles

Table tops / Desks

Light switches

Computers

Sinks/basins

3 times daily + between each patient

3 times daily + between each patient

*Effective inactivation of the virus can be achieved with a 10 minute dwell time for chlorine bleach solutions. Other disinfectants may vary, follow the guidance on the packaging

Worker SafetyCopy Link!

  1. See these tables for PPE needed for clinical and support staff.
  1. Wear disposable gloves for all tasks in the cleaning process, including handling trash.
  2. Wash hands with soap and water immediately after gloves are removed. If water is unavailable, clean hands with alcohol-based hand rub.
  3. Gloves should be worn when handling and preparing bleach solutions, and eye protection should be worn in case of splashing.
  1. Close off areas to be cleaned and wait as long as practical before beginning cleaning and disinfection to minimize the potential for exposure to respiratory droplets.
  1. See air turnover and ventilation to know how long to wait before entering
  2. Open outside doors and windows to increase air circulation in the area.
  1. NEVER MIX SOLUTIONS

Soap and Water CleaningCopy Link!

  1. Always clean surfaces using a detergent or soap and water before disinfection.
  2. Remove visible pollutants (blood, secretions, excreta) completely.
  3. Damp mopping is preferable to dry mopping.
  4. Surfaces should be disinfected if they have come into direct human contact or are frequently touched.
  5. Always sterilize washing cloths, mops and other supplies used during cleaning.

DisinfectingCopy Link!

  1. Use freshly made solutions or premix. Follow manufacturer’s instructions or table below for appropriate dilution.
  2. Use proper safety measures (manufacturer guidance and worker safety measures)
  3. Wipe the area with the disinfectant solution using a cloth.
  1. Wipe cleaner regions first, then more contaminated regions.
  2. Dispose of or sterilize cloth immediately after use.
  1. Leave the disinfectant solution on the surface for sufficient time required to kill the virus (a minimum of 10 minutes for chlorine bleach).
  2. Always rinse chlorine/bleach with water after 10 minutes.
  1. Hydrogen peroxide and alcohol-based cleaners do not need to be rinsed.
Choosing the Right DisinfectantCopy Link!

Always note the listed concentration when using this product. Due to limited and changing availability of disinfectants, stocked items may change. Ensure staff working with disinfectants have knowledge for using each product correctly.

  1. For non-porous surfaces such as floors, sinks, toilets, walls: use chlorine bleach
  1. Be aware that chlorine can damage or stain computers, plastic, fabric and metal
  2. A solution of water and regular household chlorine bleach (sodium hypochlorite) can be used to create a disinfectant. Use 1 part 5% household bleach and 9 parts water (WHO). Other concentrations are below.
  1. For biomedical equipment: consult maintenance manuals to determine the best cleaning solution
  1. If maintenance manual is not available, use an Alcohol-based cleaner (if available) on biomedical equipment, electronics, computers, phones, screens, etc. If not available, clean with bleach.

Disinfecting Solution

Concentration

Directions

OK to use on

Do NOT use on

Diluted chlorine bleach (5.25% sodium hypochlorite)

0.5% (1:50)

Apply, leave for 10 minutes, rinse

Floors, desks, non-porous surfaces

Computers, phones, screens, fabric, can discolor plastic, metal

Chlorine (see table below to mix chlorine)

0.5%

Apply, leave for 10 minutes, rinse

Floors, desks, non-porous surfaces

Computers, phones, screens, fabric. Can discolor plastic, metal

Hydrogen Peroxide

0.5%

Apply

Floors, desks, non-porous surfaces, metal

Fabric

Ethanol / Ethyl Alcohol

62% minimum

Apply

Computers, Phones, Non-porous surfaces

Can discolor plastic

Isopropyl Alcohol

70% minimum

Apply

Computers, Phones, Non-porous surfaces

Can discolor plastic

Propanol

70% minimum

Apply

Computers, Phones, Non-porous surfaces

Can discolor plastic

Do NOT: use ammonia or vinegar; Do NOT: mix multiple disinfectants

Preparing Liquid Chlorine solutionsCopy Link!

% Solution

0.05 %

0.5 %

2 %

Use for:

Hands, skin, laundry, clothes

Floors, walls, equipment

Disinfection of stool, vomit, blood. Disinfection of corpses.

Bleach, 5% sodium hypochlorite

(5% active chlorine)

10 milliliters in

10 liters of water

1 liter in

10 liters of water

4 liters in

6 liters of water

Chlorine laundry powder

(30% active chlorine)

16 grams

(1 tablespoon) in

10 liters of water

16 grams

(1 tablespoon) in

1 liter of water

64 grams

(4 tablespoons) in

1 liter of water

Chlorine granules(HTH)

(70 % active chloride)

8 grams

(1/2 tablespoon) in 10 liters of water

8 grams

(1/2 tablespoon) in 1 liter of water

32 grams