PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK

On the basis of reports and questions forwarded to the Clinical Risk Managers of the Italian Network for Health Safety (INSH) from physicians working on the front line, a series of recommendations have been developed referring to documents and papers published by national institutions (ISS) and Italian and international scientific societies and journals. We have arranged the process to describe organising the work system according to the SEIPS Human Factors approach. 
This document is re-posted with permission from Riccardo Tartaglia (President of Italian Network for Safety in Health Care). 
  
 


INTRODUCTION
Based on reports and questions forwarded to the Clinical Risk Managers of the Italian Network for Health Safety (INSH) from physicians working on the front line, a series of recommendations have been developed referring to documents and papers published by national institutions (ISS) and Italian and international scientific societies and journals.
We have arranged the process to describe organising the work system according to the SEIPS Human Factors approach (1). The document is work in progress and will be subject to updates by all professionals on a continuing basis. We appreciate and welcome the contribution of all those involved in COVID-19, both providers of care and patients who have received care.
(email info@insafetyhealthcare.it) Key changes or updates between version 2.0 and 3.0 are highlighted in Red.
Changes include: • More detailed recommendations for healthcare workers safety • Updated recommendations about diagnosis, hospital treatment, children, pregnancy, labour and delivery, surgery, haemodialysis, oncologic patients, psychological safety of staff • Updated criteria for de-isolation • New cards about ophthalmology, phase 2 of emergency (characterized by reduced viral circulation), vaccinations, healthcare students' internships • Triage Covid-19 form • Multimedial links: Pharmacov for drug interactions check and Virgilio, a virtual audio guide for safe doffing.

GENERAL RECOMMENDATIONS FOR THE WORK SYSTEM
Building the Team (including communication and team culture): 1. The emergency task force should be promptly activated with a transparent chain of command, roles and responsibilities, reliable information-sharing tools and proactive approach.
The emergency task force should be pre-existing and meet periodically (i.e. 1-2 times/year), even in the absence of emergencies, to build the team.

4.
To prepare diluted bleach: use a mask, rubber gloves and waterproof apron; goggles also are recommended to protect the eyes from splashes; mix and use bleach solutions in well-ventilated areas; mix bleach with cold water (hot water decomposes the sodium hypochlorite and renders it ineffective) (82).

Promote hospitals/buildings exclusively dedicated to Covid-19 patients care.
Remember that the creation of dedicated hospitals may divert from the emergencies /emergencies network. Evaluate the fallout of the timing of treatment decisions for time-dependent diseases carefully. Consider the use of underused or quiescent equipped hospitals to help meet this need.
6. Unless the activity is suspended in the outpatient (public or private) clinics: a. avoid gatherings in waiting rooms (recommend people to wait outside, or respect the distance of at least 1m between seats); b. recommend that symptomatic subjects with fever and/or cough and/or dyspnea not to go to clinics; c. disseminate hygiene and health standards recommendations in the waiting room. 1. Define the maximum number of intensive care, sub-intensive and ordinary hospital beds that can be retrieved and activated within the organisation and an incremental activation plan (e.g. the conversion of operating rooms and sub-intensive areas into intensive care, recovery of unused hospitals) and consequently define the number of nursing staff needed at each step.
2. Make every effort to ensure numerically and professionally expert assistance concerning beds increase.
The beds can be increased with less or greater economic commitment, greater or lesser time interval, the real limited resource is the human one, in terms of specialised skills that cannot be improvised.

Alternatively, increase the number of nurses, but provide a consistent number of nurses who are experts in intensive care in each shift.
The Society of Critical Care Medicines encourages hospitals to adopt a tiered strategy of distribution of personnel in pandemic conditions (79).

Consider the following recovery criteria for intensive care:
a. previous service in intensive care; b. current or previous service in the operating room; c. current or previous service in specialised intensive care (e.g. cardiology intensive care); d. lastly, certified training (e.g. master) even without experience, in intensive care.

Use similar principles for sub-intensive respiratory units, where non-invasive mechanical
ventilation is practised. 6. Recall retired experienced staff.
7. Quickly activate multiple channels for nursing staff recruitment, favouring the new hiring of staff with previous experience (especially in intensive and sub-intensive care units). Consider continuing recruitment in the post-pandemic phase, if the risk of a new wave persists. 8. Caution should be used when introducing young graduates to the areas most exposed to the emergency. It is preferable to introduce them to other units and move experienced personnel to emergency sites. It is important to keep these symptoms in mind so as not to incur diagnostic errors and/or dangerous exposure to healthcare professionals and other patients when presented in isolated form.

Cardiovascular manifestations of Covid-19 are:
non-specific myocardial damage, myocarditis, myocardial infarction, arrhythmias, pulmonary embolism and heart failure, cardiogenic shock and cardiac arrest. Acute heart failure has been described as the first manifestation in 23% of cases and palpitations in 7%.
These manifestations may be due to the direct effect of the virus, the systemic inflammatory response, hypoxia, coagulopathy, but also to the effect of the drugs used. The presence of these manifestations aggravates the prognosis as well as the presence of pre-existing heart disease (68,69)

Pay attention to the relationships of COVID-19 with arterial (Stroke, IMA) and venous thrombotic events (VTE), as well as the negative impact on these events in COVID-19 and non-COVID patients.
The lockdown and the fear of contagion have reduced the use of hospital for pathologies other than COVID-19, even acute. The infection is associated with a more severe prognosis in subjects with Stroke. Virus-induced coagulopathy and/or systemic inflammatory response can promote thrombotic and even bleeding events, in the case of DIC. The fear of a negative interaction between infection and the use of NSAIDs has led some patients to discontinue ASA. Antivirals, such as lopinavir/ritonavir reduce the effect of antiplatelet agents such as clopidogrel and enhance that of ticagrelor. The burden of VTE is increased by the diagnostic difficulty (hypoxia and increased d-dimer are already part of the clinical picture of COVID-19; difficulty in performing angio-CT, echocardiogram and echocolordoppler in prone patients). Diagnostic tips for VTE can be signs of deep vein thrombosis, hypoxia disproportionate to the lung picture, acute deterioration of the right ventricular function (68,69).
14. Do not rely only on PO2 <60 for the diagnosis of respiratory failure, always calculate the P/F, especially in young subjects. 15. Define a "COVID-19 profile" for the rapid order entry of blood tests, including the following tests: blood count, C-RP, creatinine, blood glucose, albumin, AST ALT, bilirubin, pneumococcal and urinary legionella agents, mycoplasma and chlamydia test, PT-INR, troponin and procalcitonin. 16. Chest X-rays have limited sensitivity in the early stages of Covid-19 pneumonia. A CT scan is more sensitive but raises logistical problems. If ultrasounds competencies are available, use chest US, but disinfect US probes after contact with every Covid-19 suspected or confirmed patient (15).

Avoid nebulisation therapies for the potential spread of pathogens.
Nebulisers generate aerosol particles that can carry bacteria and viruses deep into the lung. The risk of infection transmission may increase with nebulisers as they can generate a high volume of respiratory aerosols that may be propelled over a longer distance than in natural dispersion patterns. Nevertheless, the larger particles may cause cough in both patients' and bystanders' and increase the risk of spreading the disease. So, nebulisers in patients with pandemic COVID-19 infection have the potential to transmit potentially viable COVID-19 to susceptible bystander hosts (24).

Administer intravenous fluids only if needed.
Excessive fluid administration could aggravate oxygenation and be dangerous, especially in settings where mechanical ventilation is not readily available.

Use steroids only in patients with the severe or critical disease and/or for other indications (i.e. exacerbation of COPD or asthma, septic shock/ARDS) (84).
Steroids were not associated with benefits, but rather with damage in the 2003 SARS epidemic and a delay in virus clearance in Middle Eastern Respiratory Syndrome (MERS) of 2012 (2). Two recent systematic reviews showed that steroids probably reduce mortality and mechanical ventilation need (84,85) 14. Assess thromboembolism and bleeding risk of every patient and provide appropriate thromboprophylaxis.
Consider that recovery times, and therefore hypomobility of a subject with COVID-19 are long (at least 15 days in mild forms and up to 6 weeks in severe/critical ones). Diffuse intravascular coagulation (DIC) can complicate the course (2,14).

ETHICS OF TREATMENT DECISIONS
This is a complex issue which needs to be decided in the local setting as per previous ethical frameworks.
We recommend that the ethical decision-making process is developed in anticipation of making complex decisions, rather than in reaction to the need to make a decision.
With regard to the management of patients affected by COVID-19 in intensive care, we offer some references which may assist in developing the local ethical guidelines (25, 26, 27, 28).

Other important publications (not included among references):
•

RECOMMENDATIONS FOR SURGERY
These recommendations apply to the medical staff of the operating departments concerning cases of COVID-19.
1. An operating room maintained at a negative pressure with a high-frequency air exchange (at least 25 cycles/h) or designated 'contaminated' surgery-only is sensible (71).

Surgical patients suspected or positive for SARS-CoV-2 infections should follow the local management protocol, which may include:
a. wearing specified bracelets and surgical masks, b. having their medical records marked with warning labels c. being brought through defined routes and lifts to the special isolation area for recovery (72). 6. The number of healthcare professionals present during the procedure should be limited to only those essential for patient care and procedure support (no visitors or observers allowed, no teaching/academic activities).

Consider a laparoscopic approach only after strictly evaluating the risk/benefit to both patient and staff. Precautions during laparoscopic surgery may include:
a. lower intra-abdominal CO2 pressure b. closed smoke suction system with ultra-low particulate arrestance filter (ULPA) c. minimal incisions for trocars placement (using balloon trocar, if available) d. evacuation of all smoke before the specimen extraction 8. Identify explicit priority criteria for elective surgical interventions to be performed even during an emergency (e.g. oncological interventions at high risk of progression or complication) (75).
9. It is recommended to perform a sanitisation and disinfection of the operating room for at least 1 hour, at the end of the intervention.

Team working organisation:
To stay healthy and maintain the continuity of care, surgical teams should be divided into senior and junior doctors and work for 2 weeks. After the 2 weeks, a new team will release the other. This will allow for easier replacement of team members should they fall ill, restrict potential containment of the virus to smaller staff numbers, and provide the ability to maintain some service provision and clinical care.

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. It is recommended that all the operating material be disposed of through special waste routes and use disposable material/TNT.

It is recommended that pregnant women observe general prevention measures, including using masks.
There is no evidence that the mask is hazardous to the mother and/or the foetus (87).

Reduce pregnant women's access to prenatal care, limiting it to essential visits and high-risk cases only (29).
There is no evidence of an increased risk of unfavourable maternal or foetal outcomes in the case of Covid-19. However, evidence relating to influenza and SARS-COV1 can infer that the pregnant woman is at high-risk.

Infants born to mothers with confirmed COVID-19 should be presumed to be infected.
As such, these infants should be isolated from others (30) and tested at 0, 2, 7 and 14 days.

Infants should be separated (i.e. in an individual room) from the mother with confirmed or suspected Covid-19 until the precautions based on the transmission risk of the mother
are suspended. This precaution should be thoroughly discussed between the care team and the mother, considering the clinical condition of the mother, her desire, the risk of disease transmission with the appropriate precautions (low) and the benefits of nonseparation, including the protective potential of colostrum, breastfeeding and feeding time (29, 30).
Recent indications from the CDC do not consider confirmed disease a reason to separate mother and child, even in preterm or low weight or to avoid skin-to-skin or rooming-in practice (90). However, a metaanalysis of 176 cases revealed the lack of separation of mother and newborn -if the mother is symptomatic, and therefore, particularly infectious, it significantly increases the risk of neonatal infection (89).

The discharge of mothers after childbirth must follow the recommendations for Covid-19
or suspected patients (29).

In the case of a woman with suspected SARS-CoV-2 infection or with COVID-19,
according to her clinical conditions and desire, breastfeeding should be started and/or maintained directly on the breast or with squeezed breast milk. If mother and child must be temporarily separated because of mother clinical conditions, one should help the mother maintain milk production through manual or mechanical/electric squeezing (30).
In a limited series reported to date, the virus's presence in the breast milk of infected women has not been reported, but anti-SARS-cov2 antibodies have been found (29). So breast milk would be protective.

7.
In the hospital or at home, a mother with confirmed COVID-19 or symptomatic should take all possible precautions to avoid spreading the virus to the baby, including washing hands before touching the baby and wearing a face mask when she is within 2 meters, like during breastfeeding. If using a manual or electric breast pump, the mother must wash her hands before touching the breast pump or parts of the bottle and wearing a mask during feeding. If possible, ask another healthy person, not at risk of the severe forms of COVID-19, preferably cohabiting, to give milk to the baby, always taking care to wash your hands first and wear a mask (30).
It is not yet known whether COVID-19 can be transmitted through breast milk. At present, the main concern is not whether the virus can be transmitted through breast milk, but rather whether an infected mother can transmit the virus through respiratory droplets during breastfeeding (29).

When assisting the delivery of women with confirmed or suspected Covid-19, staff must use the safety precautions provided for non-pregnant patients (30).
9. Serological screening, followed by swab monitoring every 5-7 days from the 37th week of gestation, may help avoid urgent swabs during active labour or delivery in an unclean pathway.

Centralising all non-imminent deliveries of women with confirmed infection at a referral centre can reduce nosocomial contamination.
Some centres also adopt the practice of induction at 40 + 1 weeks for this purpose. Table 5 in Appendix 29) and/or by an oral-nasopharyngeal swab, depending on the local epidemiology.

Pregnant women with suspected or confirmed SARS-COV2 infection should be treated with supportive therapies while considering pregnancy's physiological characteristics
(2).

The use of experimental therapeutic agents outside of a research study should be guided by an individual risk-benefit analysis based on the potential benefit to the mother and the foetus's safety, with the consultation of an obstetrician specialist and an ethics committee (2).
14. The decision to proceed with a preterm birth is based on many factors: gestational age, maternal conditions and foetal stability, and requires a collegial evaluation by obstetric, neonatal and intensive care specialists (depending on the mother's condition) (2).

In COVID-19 pregnant women, be very cautious in inducing lung maturity with corticosteroids, since these drugs seem to worsen the course of the infection. If possible, evaluate each case with a neonatologist.
PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK

RECOMMENDATIONS FOR PEDIATRIC PATIENTS
Keep in mind that: 1. Children and infants may be affected, but more often with asymptomatic or mild symptoms, without fever or pneumonia, more often with malaise, rhinitis and gastrointestinal symptoms (31, 32) It is hypothesised that this may be due to various reasons including more effective immune responses, a different expression of ACE2 receptors and the presence of other viruses that limit the spread of SARS-CoV2 in the respiratory tract of children (84) 2. Leukocytes are often normal, even if some have leukopenia; lymphopenia is much less frequent in children (32) (76)

In autumn and winter, many other viral diseases with similar symptoms can affect children, particularly influenza-like infections.
It is therefore recommended that both parents and caregivers are vaccinated against influenza.

For the same reason, rapid virological diagnostic tests should include, in addition to
Covid-19, other Coronaviruses, influenza, RSV, rhinovirus, and human metapneumovirus.

The criteria for the definition of Acute Respiratory Distress Syndrome (ARDS) and septic shock, the guidelines for the management of sepsis and septic shock, and non-invasive ventilation in children are different from those of adults (2).
8. Children desaturate more easily during intubation; therefore, it is vital to pre-oxygenate with 100% O2 with a mask with a reservoir before intubating (2).  a. Must obtain a telephone number to contact the patient for swab sampling and/or to communicate the result; b. provides information on how to access the swab (where and when).
Suppose the swab test does not occur in the emergency department but is performed elsewhere to another area or hospital. In that case, it is strictly suggested to use systems to avoid the loss of information. The facility/service running the buffer must report the result as soon as it is available to the patient and, if positive, to the Public Health Department for establishing active monitoring.

At the end of the hospitalisation, write clearly on the discharge letter:
a. CLINICALLY CURED patient (patient with clinical symptoms resolution for at least 3 days, but swab still positive) (35) or b. CURED patient (patient who, in addition to symptoms resolutions, has negative swab (35). CLINICALLY CURED PATIENT: write clearly on the discharge letter the requirements to be observed in the home quarantine until the swab is negative, and how to swab.
Although there is no clear supporting evidence, it is considered appropriate to suggest patient retesting no earlier than 7 days, if positive. If long-term swab positivity persists, the subject, asymptomatic for at least 7 days, is considered cured 21 days after the onset of symptoms (excluding anosmia and dysgeusia) (35). 1. Provide prevention measures and explain them to patients in home isolation, using designs, charts or pictures.

DISABLED PATIENT
2. Give clear information on symptoms that should cause concern: promote information diffusion of telephone numbers to call in case of their occurrence. d. If the corpse must remain in the mortuary, pending or after the investigations, the corpse must be placed in a specific closed body bag and stored in a dedicated refrigerated room;

Provide call centres
e. All the equipment used must be subjected to sanitisation at the end of the handling and transport operations. f. wear a long-sleeved waterproof device to protect skin and clothing;

Recommendations for autopsy investigation in cases
g. use disinfectants effective against human coronaviruses; h. clean the surfaces and apply the disinfectant, ensuring an adequate contact time for effective disinfection; i. comply with the safety precautions and warnings indicated on the product label (for example, allow adequate ventilation in restricted areas and ensure correct disposal of the unused product or used containers); j. avoid application methods that cause the production of splashes or aerosols.

7.
Regarding environmental disinfection, the available evidence has shown that coronaviruses are effectively inactivated by adequate sanitisation procedures that include the use of common hospital disinfectants, such as sodium hypochlorite (0.1% -0.5%), ethanol (62-71%) or hydrogen peroxide (0.5%). There is currently no evidence to support a greater environmental survival or a lower sensitivity of SARS-CoV-2 to the aforementioned disinfectants (45).
PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK • • • a. Hard and non-porous surfaces can be cleaned and disinfected as previously described.
b. Equipment such as cameras, telephones and keyboards, and all objects that remain in the autopsy room should be handled with gloves and appropriately disinfected after use.
c. Cleaning activities must be supervised and periodically checked to ensure that the correct procedures are followed. Sanitation personnel must be properly trained and equipped with suitable PPE.
d. After cleaning and removing the PPE, wash hands immediately. Avoid touching the face with gloved or unwashed hands.
e. Environmental disinfection must include cleaning with water and detergent soap on all vertical and horizontal surfaces, followed by disinfection with hospital disinfectants effective against SARS-CoV-2.
f. For environmental decontamination, it is necessary to use dedicated or disposable equipment. Reusable equipment must be decontaminated after use with a chlorine-based disinfectant. The use of special trolleys is strongly recommended, different from those used for cleaning common areas.
g. The instruments used for autopsies should be autoclaved or treated through chemical sterilisers. 5. Educate healthcare workers who are exposed to trauma about the effects of cumulative stress. The training should be delivered online because they can do it at their convenience, or via educational leaflets, rather than finding the time to spend on a day course.
The education about psychological trauma may lead to better understanding, better recognition of symptoms in oneself and others, less judgment, reduced stigma, and positive relationships with others in the workplace can positively impact psychology.

Maintain teamwork and effective leadership while at the same time providing individuals with the opportunity to provide input into the decisions that affect their lives.
Staff often experience severe emotional stress during viral outbreaks. The nursing staff often feels the greatest level of stress due to their constant contact with sick patients, who may not be improving despite the nursing staff's best efforts. Physicians usually cope somewhat better with this situation because they can make treatment decisions and are less directly involved in implementing patient care.

Be receptive to suggestions from nursing staff and support personnel.
Input is empowerment and provides a sense that critical staff retain some control over their situation. If suggestions are not acted on, clear explanations of why they were not should be provided, and alternatives should be explored. 8. The administration needs to be supportive of staff and not be seen as pedantic or overly controlling In cases where staff and support personnel did not feel appreciated or listened to, there was a high degree PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK • • • of dissatisfaction and an increased occurrence of absenteeism and staff strikes, which further reduced personnel in an already-strained system.

Keep in mind that lack of clarity around tasks is associated with significant stress, and poor leadership is linked to staff stress (includes ad hoc planning) (96).
10. Make an effort to ensure that your office and/or organisation has a viable plan to monitor the course of the outbreak and take rapid and appropriate action if needed.

Medical and mental health clinicians are likely to encounter patients experiencing various levels of emotional distress about the outbreak and its impact on them, their families, and their communities.
We must consider that COVID-19 patients have prolonged hospital stays. In the early stages, they will experience the concern of having a severe manifestation of the disease with the possibility of being intubated. Staff shortages may impact on their treatment.

Providers should acknowledge uncertainty about emerging diseases and help patients understand that there is often an emotional component to potential health concerns.
3. Providers should be aware that the symptoms might extend beyond classic mental health symptoms, including relational struggles, somatic, academic, or vocational issues.

Providers should also consider the following recommendations for promoting patients' mental wellbeing during emerging infectious disease outbreaks:
a. Be informed: Obtain the latest information about the outbreak from credible public health resources to provide accurate information to your patients.

b. Educate: Healthcare providers are on the front lines of medical intervention and in a position to influence patient behaviours for protecting individual, family, and public health.
Psycho-education is of utmost importance in the aftermath of disasters. Patient education plays a critical role in containing the disease and mitigating emotional distress during outbreaks. Depending on the nature of the outbreak, this can range from education about basic hygiene such as hand-washing and cough etiquette, to more complex medical recommendations for prevention, diagnosis, and treatment.

6.
Let patients know what you, your office, or your organisation are doing to reduce exposure risk.

Correct misinformation
In this age of social media, misinformation can spread quickly and easily, causing unnecessary alarm. If patients present you with inaccurate information about the outbreak, correct their misconceptions and direct them to vetted public health resources.

PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK • • •
The excess media exposure to coverage of stressful events can result in negative mental health outcomes. Use trusted media outlets to gather the information you need, then turn them off-and advise your patients to do the same.

Anticipate and counsel potential emotional stress
Emotional distress is a common mental reaction in uncertain and potentially lifethreatening situations, such as the COVID-19 epidemic. An excellent first step for mitigating your patients' stress is to acknowledge that it exists and help normalise it ("I see that you're stressed, and that's understandable. Many people are feeling this way right now.").

Teach people to recognise the early signs of emotional stress, including anxiety, fear, insomnia, difficulty in concentration, deteriorating interpersonal relationship, situation avoidance at work or daily living, unexplained physical symptoms, and increased use of alcohol or tobacco.
This will help them become more aware of the state of their mental health and stress address emotional stress before it becomes difficult to manage.

Discuss strategies to reduce distress, which can include:
a. Being prepared (e.g., developing a personal/family preparedness plan for the outbreak). b. Taking simple preventive measures (e.g., frequent handwashing). c. Maintaining a healthy diet and exercise regimen. d. Talking to loved ones about worries and concerns. e. Engaging in hobbies and activities you enjoy, to improve your mood. f. If a patient is experiencing severe emotional distress or has a diagnosable mental illness, refer them for specialised mental health care.

Infectious risk containment actions
a. Provide surgical masks, measure body temperature, assess Covid-19 related symptoms and contacts and require hand-wash for any healthcare worker (HCW) entering the facility. If there is a history of close contact with positive COVID-19 and/or even mild symptoms, they should not be accepted within the facility b. HCWs should always be assigned to the same department and the same section during the emergency c. Monitoring of the patient's clinical condition should be carried out at least twice a day d. Rehabilitation activities must be reformulated on a "visible" social distancing since the use of masks is not conceivable, nor hands washing is practicable e. In residential facilities rehabilitation activities should be carried out mainly outside f. Identify an isolation zone to be reserved for suspicious cases, pending diagnostic confirmation (COVID-19 area). The COVID-19 area should be set up in an area wholly detached from the rest of the department, possibly with an independent entrance. It must be sanitised at least 2 times a day, keeping it always ready, even in the absence of cases to be isolated g. Swabs should be performed immediately on any suspicious case and his/her contacts h. Immediate isolation of the positive patient and close contacts i. The clinical management of COVID-19 requires a multidisciplinary medical team including infectious disease specialist, anaesthetist, internist and psychiatrist j. Beware of the numerous therapeutic interactions of psychotropic drugs

SPECIFIC ACTIONS
1. Organise two functional areas, possibly with single rooms and dedicated staff: a. a "filter" area for the reception of new guests, equipped with a doctor's certificate of absence of symptoms/suspect contacts and/or negative swab; or guests returned from the hospital with a diagnosis other than COVID-19 and negative swab before discharge b. "isolation" area inside the residence for suspect cases awaiting diagnostic confirmation; guests who have returned from the hospital who have only been cured clinically (swab still positive); or to treat confirmed cases, if highly specialised care is not necessary (hospital).

Upon arrival in the office, the physician must wear a washable uniform (at least 2 should be available), working closed shoes and wear PPE (FFP2, disposable goggles and gloves for non-suspicious cases; FFP3, disposable gown, disposable waterproof full suit, headset, glasses, visor, cover shoes and 2 pairs of gloves for visits of suspicious cases). Disposable devices must be changed on each visit.
PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK • • •

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AT THE DISTRICT LEVEL

Establish special continuity of care units that support general practitioners in home management (swabs, laboratory tests, home surveillance).
Early identification and treatment at home are useful to reduce the congestion of hospitals and intensive care in particular, as they would be associated with a lesser evolution of the disease.
IDENTIFICATION and MANAGEMENT OF SUSPECTED or CONFIRMED CASES (63)

RECOMMENDATIONS FOR HAEMODIALYSIS (58)
Patients undergoing hemodialysis have a high risk of developing COVID-19 infection due to old age, multimorbidity or immunosuppression. Furthermore, the need for frequent access to Dialysis Centres, using transport systems that are often shared with other patients, and staying in closed and crowded environments for the entire duration of the treatment, can increase the risk of infection.

COVID-19 confirmed, suspected, or under investigation patients should have separate access, rooms and staff.
For other outpatient services, we recommend compliance with the outpatient section in the General Recommendations and Recommendations for cancer and immunosuppressed patients, and: 1. Ask patients to always inform the hemodialysis facility in advance by telephone in the event of symptoms onset, before attending the facility.
2. Optimise transports to haemodialysis: encourage patients to use their own means, and space appointments sufficiently to avoid crowds in the waiting room. Ask patients to wait in the car and advise them not to arrive early. Eliminate multiple transports and organise single transports; sanitise vehicles after transporting affected or suspected patients.
3. Arrival at the haemodialysis centre: the patient, accompanied to the centre by staff, must wear a surgical mask; seats must be spaced at least 1 meter apart, in the waiting room; access to the changing room must be restricted. Table 5 in Appendix), body temperature and peripheral O2 saturation measurement. Patients with body temperature ≥37.5 o C and/or oxygen saturation ≤96% are identified as possibly infected.

If screening does not reveal situations to be investigated, the patient should be accompanied to the dialysis room. If, on the other hand, the screening interview or the parameters suggest a possible infection, then the following options can arise:
a. haemodialysis that is essential: perform the haemodialysis session in isolation, as if the patient was Covid-19 positive in the designated room for suspected cases. At the end of the session, refer the patient according to the pre-established inhospital clinical pathway. If possible, carry out urgent swabs and blood tests at the beginning of the haemodialysis session b. haemodialysis that can be delayed: refer the patient according to the preestablished in-hospital clinical pathway.
6. During haemodialysis session: nursing staff must verify that, in the presence of coughing or sneezing, that disposable handkerchiefs are used with a subsequent change of gloves and masks, that no signs and/or symptoms referable to a fever arise, and that the patient does not remove his/her PPEs.

To examine visual acuity without being hindered by the glasses'
fogging, ask the patient to wash their spectacles with soapy water (the soapy water acts as a surfactant film reducing the surface tension and preventing the phenomena of fogging) immediately before putting on the mask (93).

Keep in mind that ophthalmic lenses (20 D, 90 D, 78 D, Goldmann triple mirror and super view lenses)
, usually used for fundus examination, cloud over, making examination impossible and that it is not possible to adopt the above expedient due to glare and reflections that would occur with diagnostic lenses. The most practical action in such cases is to uncover the nose. However, this increases contagion risk, especially if plastic PATIENT SAFETY RECOMMENDATIONS FOR COVID-19 PANDEMIC OUTBREAK • • • screens are not used for slit lamp. Alternatively, it is recommended that the patient wears a facial filter (FFP2-3), since its tighter fit prevents the lenses' fogging (94).
6. Due to physical proximity, during surgery and intravitreal injection, the patient and physician should wear respiratory protection appropriate to the degree of risk (93).
7. Be aware that phacoemulsification produces aqueous aerosol as it sculpts the grooves in the core. Although the risk of contagion seems minimal, it is recommended to instil a 5% povidone-iodine solution before performing cataract surgery, reducing the size of the main port to 2.2 mm (to reduce aerosol generation), allow one complete fluid exchange before the start of emulsification through an infusion/aspiration, lasting at least 6 seconds, and finally covering the eye with hydroxypropylmethylcellulose (HPMC) during the entire emulsification procedure. Although it is not an emergency procedure, it may have to be performed in the context of a more complex operation (e.g. Vitrectomy for retinal detachment) (95).

MEASUREMENT (59, 60)
It is important to measure the impact of our actions. We include some measures that may be of use.

Outcome measures
Outcome measures should be collected to support the monitoring of effective provider (hospital) epidemic/pandemic response including the capacity to adequately treat patients with other common severe conditions like heart attacks, strokes, trauma, COPD to assure that the health of the public is protected to the fullest extent possible.