Views:1 Author:Site Editor Publish Time: 2020-06-08 Origin:Site
Faced with an unknown virus, sharing and collaboration are the best remedy.
The publication of this Handbook is one of the best ways to mark the courage and wisdom our healthcare workers have demonstrated over the past two months.
This is an unprecedented global war, and mankind is facing the same enemy, the novel corona- virus. And the ﬁrst battleﬁeld is the hospital where our soldiers are the medical workers.
To ensure that this war can be won, we must ﬁrst make sure that our medical staﬀ is guaranteed suﬃcient resources, including experience and technologies. Also, we need to make sure that the hospital is the battleground where we eliminate the virus, not where the virus defeats us.
Today, with the spread of the pandemic, these experiences are the most valuable sources of information and the most important weapon for medical workers on the battleﬁeld. This is a brand-new disease, and China was the ﬁrst to suﬀer from the pandemic. Isolation, diagnosis, treatment, protective measures, and rehabilitation have all been started from scratch, but we hope that with the advent of this Handbook doctors and nurses in other aﬀected areas can learn from our experience when entering the battleﬁeld and they won't have to start from zero.
This pandemic is a common challenge faced by mankind in the age of globalization. At this moment, sharing resources, experiences and lessons, regardless of who you are, is our only chance to win. Because the real remedy for epidemics is not isolation, but cooperation.This war has just begun.
1.All staﬀ at the healthcare facilities must wear medical surgical masks;
2.All staﬀ working in the emergency department, outpatient department of infectious diseases, outpatient department of respiratory care, department of stomatology or endoscopic examina- tion room (such as gastrointestinal endoscopy, bronchoﬁbroscopy, laryngoscopy, etc.) must upgrade their surgical masks to medical protective masks (N95) based on Level I protection;
3.Staﬀ must wear a protective face screen based on Level II protection while collecting respirato- ry specimens from suspected/conﬁrmed patients.
I.Personalized, Collaborative and Multidisciplinary Management
FAHZU is a designated hospital for COVID-19 patients, especially severe and critically ill individuals whose condition changes rapidly, often with multiple organs infected and requiring the support from the multidisciplinary team (MDT). Since the outbreak, FAHZU established an expert team composed of doctors from the Departments of Infectious Diseases, Respiratory Medicine, ICU, Laboratory Medicine, Radiology, Ultrasound, Pharmacy, Traditional Chinese Medicine, Psychology, Respiratory Therapy, Rehabilitation, Nutrition, Nursing, etc. A comprehensive multidisciplinary diagnosis and treatment mechanism has been established in which doctors both inside and outside the isolation wards can discuss patients’ conditions every day via video conference. This allows for them to determine scientiﬁc, integrated and customized treatment strategies for every severe and critically ill patient.
Sound decision-making is the key to MDT discussion. During the discussion, experts from diﬀerent departments focus on issues from their specialized ﬁelds as well as critical issues to diagnoses and treatment. The ﬁnal treatment solution is determined by experienced experts through various discussions of diﬀerent opinions and advice.
Systematic analysis is at the core of MDT discussion. Elderly patients with underlying health conditions are prone to becoming critically ill. While closely monitoring the progression of COVID-19, the patient's basic status, complications and daily examination results should be analyzed comprehensively to see how the disease will progress. It is necessary to intervene in advance to stop the disease from deteriorating and to take proactive measures such as antivirals, oxygen therapy, and nutritional support.
The goal of MDT discussion is to achieve personalized treatment. The treatment plan should be adjusted to each person when considering the diﬀerences among individuals, courses of disease, and patient types.
Our experience is that MDT collaboration can greatly improve the eﬀectiveness of the diagnosis and treatment of COVID-19.
II.Etiology and Inﬂammation Indicators
Detection of SARS-CoV-2 Nucleic Acid
Appropriate specimens, collection methodds and collection timing are important to improve detection sensitivity. Specimen types include: upper airway specimens (pharyngeal swabs, nasal swabs, nasopharyngeal secretions), lower airway specimens (sputum, airway secretions, bronchoalveolar lavage ﬂuid), blood, feces, urine and conjunctival secretions. Sputum and other lower respiratory tract specimens have a high positive rate of nucleic acids and should be collected preferentially. SARS-CoV-2 preferentially proliferates in type II alveolar cells (AT2) and peak of viral shedding appears 3 to 5 days after the onset of disease. Therefore, if the nucleic acid test is negative at the beginning, samples should continue to be collected and tested on subsequent days.
1.2Nucleic Acid Detection
Nucleic acid testing is the preferred method for diagnosing SARS-CoV-2 infection. The testing process according to the kit instructions is as follows: Specimens are pre-processed, and the virus is lysed to extract nucleic acids. The three speciﬁc genes of SARS-CoV-2, namely the Open Reading Frame 1a/b (ORF1a/b), nucleocapsid protein (N), and envelope protein (E) genes, are then ampliﬁed by real-time quantitative PCR technology. The ampliﬁed genes are detected by ﬂuorescence intensity. Criteria of positive nucleic acid results are: ORF1a/b gene is positive, and/or N gene/E gene are positive.
The combined detection of nucleic acids from multiple types of specimens can improve the diagnostic accuracy. Among patients with conﬁrmed positive nucleic acid in respiratory tract, about 30% - 40% of these patients have detected viral nucleic acid in the blood and about 50% - 60% of patients have detected viral nucleic acid in feces. However, the positive rate of nucleic acid testing in urine samples is quite low. Combined testing with specimens from respiratory tract, feces, blood and other types of specimens is helpful for improving the diagnostic sensitivity of suspected cases, monitoring treatment eﬃcacy and the management of post-discharge isolation measures.
Virus Isolation and Culture
Virus culture must be performed in a laboratory with qualiﬁed Biosafety Level 3 (BSL-3). The process is brieﬂy described as follows: Fresh samples of the patient's sputum, feces, etc. are obtained and inoculated on Vero-E6 cells for virus culture. The cytopathic eﬀect (CPE) is observed after 96 hours. Detection of viral nucleic acid in the culture medium indicates a successful culture. Virus titer measurement: After diluting the virus stock concentration by a factor of 10 in series, the TCID50 is determined by the micro-cytopathic method. Otherwise, viral viability is determined by plaque forming unit (PFU).
Since Behring and Kitasato reported the therapeutic eﬀects of diphtheria antitoxin plasma in 1891, plasma therapy has become an important means of pathogen immunotherapy for acute infectious diseases. The disease progression is rapid for severe and critically ill patients of an emerging infectious disease. In the early phase, the pathogens damage the target organs directly and then lead to severe immuno-pathological damage. The passive immune antibodies can eﬀectively and directly neutralize the pathogens, which reduces the damage of the target organs and then block the subsequent immune-pathological damages. During multiple global pandemic outbreaks, WHO also emphasized that “convalescent plasma the rapy is one of the most recommended potential therapies, and it has been used during other epidemic outbreaks”. Since the outbreak of COVID-19, the initial mortality rate was rather high due to the lack of speciﬁc and eﬀective treatments. As mortality rate is an important metric that the public concerns, clinic treatments which can reduce the fatality rate of critical cases eﬀectively are key to avoid public panic. As a provincial-level hospital in Zhejiang province, we have been responsible to treat the patients from Hangzhou and the critically ill patients of the province. There are abundant potential convalescent plasma donors and critically ill patients who need convalescent plasma treatment in our hospital.
ALSS nursing care is mainly divided into two diﬀerent periods: nursing care during treatment and intermittent care. Nursing staﬀ should closely observe the conditions of patients, standardize the operating procedures, focus on key points and deal with complications timely in order to success- fully complete ALSS treatment.
Overview of FAHZU
Founded in 1947, The First Aﬃliated Hospital, Zhejiang University School of Medicine (FAHZU), is the earliest aﬃliated hospital of Zhejiang University. With six campuses, it has now evolved into a medical center integrating health care, medical education, scientiﬁc research and preventative care. In terms of overall strength, FAHZU is ranked 14th in China.
As a large-size general hospital, it currently has over 6,500 employees, including academicians of the Chinese Academy of Engineering, National Distinguished Young Scholars and other outstanding talents. There is a total of 4,000 beds available to patients in FAHZU. Its main campus handled 5 million emergency and outpatient visits in 2019.
Over the years, FAHZU has successfully developed a number of renowned programs in organ transplantation, pancreatic diseases, infectious diseases, hematology, nephrology, urology, clinical pharmacy, etc. FAHZU helps many realize the radical resection of cancer and enjoy long-term survival. FAHZU is also an integrated provider of liver, pancreas, lung, kidney, intestine and heart transplantation. In the ﬁght against SARS, H7N9 avian ﬂu and COVID-19, it has gained rich experience and fruitful results. As a result, its medical professionals have published many articles in journals such as New England Journal of Medicine, the Lancet, Nature and Science.
FAHZU has been extensively engaged into overseas exchanges and collaboration. It has established partnerships with over 30 prestigious universities around the world. Productive achievements have also been accomplished through exchange of our medical experts and technologies with Indonesia, Malaysia and other countries.
Adhering to the core value of seeking truth with prudence, FAHZU is here to oﬀer quality health care to everyone in need.