Pragmatic Recommendations for Safety while Caring for Hospitalized Patients with Coronavirus Disease 2019 (COVID-19) in Low- and Middle-Income Countries

Abstract

Infection prevention and control measures to control the spread of COVID-19 are challenging to implement in many low- and middle-income countries (LMICs). This is compounded by the fact that most recommendations are based on evidence that mainly originates in high-income countries. There are often availability, affordability, and feasibility barriers to applying such recommendations in LMICs, and therefore, there is a need for developing recommendations that are achievable in LMICs. We used a modified version of the GRADE method to select important questions, searched the literature for relevant evidence, and formulated pragmatic recommendations for safety while caring for patients with COVID-19 in LMICs. We selected five questions related to safety, covering minimal requirements for personal protective equipment (PPE), recommendations for extended use and reuse of PPE, restriction on the number of times healthcare workers enter patients’ rooms, hand hygiene, and environmental ventilation. We formulated 21 recommendations that are feasible and affordable in LMICs.

A Brazilian Inter-Hospital Candidemia Outbreak Caused by Fluconazole-Resistant Candida parapsilosis in the COVID-19 Era

“…The emergence of FRCP candidemia cases in a Brazilian cardiology referral center that receives unstable cardiac patients from an adult cancer center under a large FRCP outbreak suggested an inter-hospital transmission of isolates through ICU patients sharing. Despite the recommended hand hygiene with alcohol-based hand sanitizer during the COVID-19 pandemic [26] being reinforced, as well as environmental decontamination, candidemia by FRCP isolates remained an ongoing challenge in both hospitals throughout 2020 (Figure 2). The cancer center reduced the number of hospitalizations, including those in the ICU, and surgeries to prevent nosocomial SARS-CoV-2 transmission.…”

Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review

“…Many articles described specific recommendations for performing intubation15–19 or for certain areas, such as psychiatric services,20–22 orthopaedics,23 haemodynamic,24 intrahospital transport,25 oncology,26 27 field hospitals,28 29 paediatrics,30–34 diagnostic centres,35–37 inpatient units,38–43 endoscopy and gastroenterology centres,44–48 gynaecology and obstetrics,40 49–55 emergency units,56–60 intensive care unit40 41 56 61–68 and the most common was the surgical centres 48 61 69–99. Other articles made recommendations for the hospital service as a whole 19 58 64 100–138. Most documents are from the USA (n=34, 27.2%), followed by Brazil (n=21, 16.8%) and multicentre studies (n=17, 13.6%).…”

“…The reorganisation of the health services category addresses 17 recommendations related to the flow of patients, the management of human and material resources and the reorganisation of the hospital environment in order to prevent the transmission of COVID-19. It is recommended that all patients are considered suspects47 70 80 90 91 101 128 and undergo risk stratification20 21 23 24 27 31 32 36 39 43–47 49 53 66 70 72–74 76 81 85 91 93 100–102 108 110 119 125 126 133 135 139 with a history of clinical and epidemiological data20 22–24 39 45–47 49 72 81 92 93 95 96 101 124–126 133–135 and a test20 22 23 26 30 39 48–51 53 61 65 68 72 73 81 84 90 92 96 102 110 119 124 133 of RT-PCR,23 36 47 69 72 81 87 88 91 96 119 125 126 133 134 ELISA23 47 or nasal swab84 95 101 at admission screening,21 22 36 39 49–51 53 69 95 108 133 in the preoperative period,23 26 47 48 61 69 72 87 90 95 102 124 in referrals31 84 and before non-emergency procedures involving airway approaches 66 79 95…”

“…Suspected and confirmed patients should be isolated,20 21 23 30 32 38 40 42 43 50–54 59 60 66 69 76 78 91 96 100–102 104 108 110 119 124 126 129 133 134 139 preferably in single rooms with negative pressure 65 67 76 79 112 117 120 123 134. If this is not possible, a minimum distance of 1 m should be maintained between beds in collective isolation 20 32 38 40 53 120 123 128 131 139.…”

“…Aerosol-generating surgeries and procedures must be performed in rooms with negative pressure 18 19 30 44 46–48 53 62 66 67 69 70 75–77 79 84 87 89 91–94 98 120 128 131 137 139. If this is not possible, for procedures it is recommended to adapt a room that has natural ventilation with open windows with bars,18 35 56 100 110 120 137 139 high efficiency particulate air filter44 47 73 84 89 98 112 120 137 139 and doors to other environments must be kept closed 47 67 70 89 91 100 120 139…”