Facilities Management and Operations

Please note that as of April 2023, this website is no longer actively being updated.Copy Link!

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!

In settings where air is recirculated (including air conditioning system), air filtration is important for infection control and prevention. Air recirculation without filtration may increase risk of transmitting airborne pathogens. (Mousavi et al).

Airborne Infection and Isolation Rooms (AIIR, or negative pressure rooms) are the ideal rooms for PUIs and COVID patients. This will typically be done by ventilation systems that ensure an adequate number of air exchanges per hour. Natural ventilation is not recommended for smaller airborne isolation rooms as it does not reliably achieve the needed air exchanges per hour. The efficacy of natural ventilation systems depends on both building design and outdoor air movement as well as human factors such as ensuring windows remain open (Nardell). For a discussion of the use of open wards versus private rooms see Open Shared Wards.

When AIIRs are not available, air quality and safety measures must be taken to reduce infection risk. Strategies in these situations include:

1. Optimizing ventilation to achieve as close to 12 Air Changes per Hour (ACH) as possible, including the addition of mixed mechanical and natural ventilation schemes.
2. Ensuring that all recirculated air is adequately filtered through viral filtration systems (like HEPA).
3. If augmenting ventilation is not an option, such as in some resource limited settings, windows that open to the outdoors away from trafficked areas (and not into other patient care areas) can decrease transmission risk. Here is a New York Times visualization on the impact of opening windows.

Tool: The Epidemic Task Force established by ASHRAE (The American Society of Heating, Refrigerating and Air-Conditioning Engineers) technical guidance for ventilation and filtration healthcare settings
Tool: The ASHRAE Epidemic Task Force website with additional resources.

Air turnover: Key recommendations include improving direction of airflow in the direction of “more clean” to “less clean” (more important than air exchange rate), increasing filtration, and maintaining humidity at 40-60%. Minimum recommendation for COVID wards and rooms is 12 total air exchanges per hour (ASHRAE, CDC).

In settings where air needs to be recirculated to maintain conditioned spaces for patient comfort or where outside air changes are not feasible, recirculated air should be filtered through a viral filter (e.g. HEPA filtration system). In these cases, upper room germicidal ultraviolet (GUV) air disinfection may also provide infection control benefits. See section on upper room GUV below.

Viral Filters: High efficiency particulate air (HEPA) filters are notably useful for enhancing filtration. If replacing existing filters with higher-efficiency ones, care must be taken to balance pressure drop and fan speed to avoid unintentionally reducing air flow to the area. Some facilities have installed portable plastic anterooms outfitted with HEPA filters to simultaneously filter areas with high viral load and create a negative pressure seal (Mousavi et al).

Upper Room Germicidal Ultraviolet (GUV): Upper room GUV is proven to reduce transmission of tuberculosis and other infectious diseases in spaces with high potential of transmission (Nardel et al). The effect of upper room GUV is most prominent in closed spaces that use recirculating air conditioning systems and have low air change rates. In order to achieve maximum effectiveness of upper room GUV, low speed air circulation fans should be utilized to help circulate air within the space and ensure that air is continuously moving through the GUV zone. Consult a professional for design and installation of upper room GUV systems.

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.

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.

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.

4. 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).
5. 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.
6. 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.

3. 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).
4. Planning for these possibilities in advance is critical to ensure equity and to protect individual healthcare workers from needing to make resource allocation decisions.
5. 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.

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

CLINICAL AREAS (Including Isolation Units)

Recommended Minimum Cleaning and Disinfecting Frequencies

*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.

2. 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.

3. 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.

4. Leave the disinfectant solution on the surface for sufficient time required to kill the virus (a minimum of 10 minutes for chlorine bleach).
5. 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.

2. 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.

Preparing Liquid Chlorine solutionsCopy Link!

Disposal of ExcretaCopy Link!

Updated Date: September 24, 2020

1. Feces must be treated as a biohazard and handled as little as possible.
2. Anyone handling feces should follow WHO contact and droplet precautions and use PPE, including long-sleeved gowns, gloves, boots, surgical masks, and goggles or a face shield.
3. Conduct hand hygiene when there is suspected or direct contact with feces. Soap and water are preferred to the use of an alcohol-based hand rub if hands are visibly dirty.
4. Excreta collected in diapers or bedpan should immediately be disposed of in a separate toilet or latrine that is used only by suspected or confirmed COVID-19 patients.
5. Dispose of diapers as infectious waste, as they would be in all situations.
6. Bedpans should be cleaned with a neutral detergent and water, disinfected with a 1% chlorine or 0.5% sodium hypochlorite solution, and rinsed with clean water. Dispose of rinse water in a drain, toilet, or latrine.

LaundryCopy Link!

1. For handling soiled laundry used by COVID-19 patients, wear appropriate PPE, including heavy duty gloves, mask, eye protection, a long-sleeved gown, an apron if the gown is not fluid resistant, and boots or closed shoes.
2. Place soiled laundry in clearly labelled, leak-proof bags or containers after carefully removing any solid excrement and putting it in a covered bucket to be disposed of in a toilet or latrine.
3. Machine wash with warm water at 60−90° C with laundry detergent. The laundry can then be dried according to routine procedures.

1. If machine washing is not possible, use a large drum to soak in hot water. Use a stick to stir and avoid splashing. Empty drum and soak linens in 1% chlorine for approximately 30 minutes. Rinse laundry with clean water and allow to dry fully in sunlight.
2. Carefully remove excreta from surfaces (such as linens or floor) with a towel and immediately place it in a toilet or latrine. Treat soiled disposable towels as infectious use and reusable towels as soiled linens.

Dead Body ManagementCopy Link!

Updated Date: September 24, 2020

There is a risk of transmission of COVID-19 post-mortem. While taking appropriate precautions during the post-mortem period, it is essential to maintain the dignity of the deceased and respect relevant cultural and religious traditions.

Preparation of body for transfer from inpatient isolation ward

1. All staff should perform hand hygiene before and after contact with the body.
2. Ensure proper use of PPE, including gown, goggles/face shield, surgical mask and gloves.
3. Remove all tubes, IVs and other lines from the patient.
4. Wrap the body in cloth for transfer to the mortuary area.
5. Ensure that all used equipment including the patient’s bed are cleaned, as per cleaning and disinfection guidelines.
6. In the following circumstances a leak-proof or a double plastic bag may be necessary:

1. Excessive fluid leakage
2. Management of a large number of bodies
3. Other situations where use of a body bag is recommended by standard mortuary procedures

Mortuary procedures

1. Ensure that mortuary staff wear appropriate PPE, including gown, goggles/face shield, surgical mask and gloves. If activities have the potential to generate aerosols (such as autopsy), particulate respirators (N95 or FFP2 or its equivalent) should be worn.
2. Ensure daily cleaning of the mortuary with chlorine or bleach per instructions in previous sections.

Transfer to family

1. If culturally appropriate, place the body in a leak-proof or a double plastic bag.
2. Alternatively, cover the body with a sheet. Plastic or cloth sheeting can be used.
3. If covering the body is not possible, place a non-medical/fabric mask on the deceased before any movement or manipulation of the body

Counseling for the family

1. Recommend that gloves be worn by people with physical contact with the deceased.
2. Those preparing the body should instruct family and friends not to kiss or touch the deceased.
3. Anyone who has assisted in preparing the body should wash hands thoroughly with soap and water when finished.

1. Clothing worn during contact with the body should be immediately removed and washed after the procedure, or an apron or long-sleeved fluid resistant gown should be worn.

4. If any ceremonial or burial activity may involve the splashing of bodily fluids, eye protection and medical masks should be word

Laboratory GuidelinesCopy Link!

Updated Date: September 24, 2020

The most commonly used and reliable assays for diagnosis of COVID-19 have been those based on molecular testing (NAAT), mainly RT-PCR (reverse transcriptase polymerase chain reaction). However, this technology requires highly skilled personnel, well-controlled laboratory environments, more expensive equipment, and in some instances long turnaround times. On the other hand, Rapid Tests are faster, less costly, simpler and easier to use, though their sensitivity and specificity are generally lower than those reported for RT-PCR assays. Choice between the two is covered in Testing (including WHO guidance on when it is acceptable to use RDTs). The WHO Interim Guidance also provides guidance on selection of tests for procurement and implementation. Ten factors are listed for consideration when selecting rapid Antigen tests such as reported performance, cost, kit contents, quality of available validation data, etc. It is noteworthy to mention that the antigen test procured by PIH, STANDARD Q COVID-19 Ag test is included in the validation studies performed by FIND as well as in the Emergency Use Listings assessment pipeline from WHO. Based on several verification studies performed at different countries, the overall sensitivity of this Ag test is 92.66% and the specificity is 99.25% under the conditions tested.

General aspects of the laboratory procedures:

1. Controls: Laboratory procedure for external quality controls for antibody and antigen rapid tests. Good laboratory practices recommend the use of control materials. Users should follow the appropriate guidelines concerning the frequency and use of external control materials.
2. Instructions: The package insert must be read completely before performing the test. Failure to do so may yield inaccurate test results.
3. PPE. PPE must be worn correctly. See PPE During Testing.
4. Biosafety measures: Observe biosafety measures and good laboratory practices when handling specimen or performing the test, such as:

1. Clean work surface with disinfectant available before starting work.
2. Place absorbent bench liner on work surface to capture potential splatters and splashes.
3. Clean up spills thoroughly using an appropriate disinfectant.
4. Handle all specimens as if they contain infectious agents
5. Dispose of all specimens and test materials as biohazard waste.
6. Laboratory chemical and biohazard wastes must be handled and discarded in accordance with all local, state, and national regulations.
7. Clean the workbench and all non-disposable materials with disinfectant at the end of the work.

5. Test kit and reagent storage: Store kits and reagents according to manufacturers’ specifications.

1. Do not freeze or thaw unless instructed to
2. Do not reuse elements that are not marked for reuse
3. Do not mix buffers or reagents from different lots
4. Do not use expired testing materials
5. Do not use any damaged or unsealed products

PIH has offered specific SOPs for rapid tests and corresponding external controls that contain: Product Description, Test Principle, Warnings and Precautions, Sample Collection, Test Procedure, External Quality Control and Interpretation and Limitation of Test.