UNIFIED COVID-19

ALGORITHMS

Section 1
GUIDELINES FOR PRIMARY CARE
 TABLE OF CONTENTS

Introduction to Algorithm Interpretation page 1

Classification of COVID-19 Cases (FIGURE 1A) page 2
Community Quarantine Protocol (FIGURE 1B) page 3
Contact Tracing Protocol (FIGURE 1C) page 4
Management of Pregnant Patients (FIGURE 1D) page 5
Newborn Care and Breastfeeding (FIGURE 1E) page 6
References page 7
 INTRODUCTION

The clinical algorithm (flow chart) is a text format that is specially suited for
representing a sequence of clinical decisions which are intended to improve and
standardize decisions in delivery of medical care. For the purpose of clarity, a typical
clinical algorithm is depicted with basic symbols that represent clinical steps in decision-
making:

Clinical State Decision Y Action Connection

Box Box Box Box

1. The rectangle with rounded edges depicts the current clinical state of an individual
patient;
2. The hexagon is decision box which contains a question answerable by yes or no; one
arrow going to the right signifies “yes”, and one arrow going downwards signifies
“no”;
3. The rectangle with sharp edges depicts the action to be done; and
4. The oval depicts connection to another algorithm in a different page.

Note that the following algorithms are adapted from multiple guidelines as
released by the World Health Organization, Department of Health, and other societies.
This document was also reviewed by different experts with the end-goal of having a
summarized and comprehensive compilation of guidelines that will aid in management of
COVID-19 patients by healthcare workers from both the community and hospital levels.

Lastly, while these patient-centered algorithms intend to summarize and

simplify recommendations, these may be subject to change as evidence emerges and
guidelines are updated. Any recommendations on patient care are not absolute. Final
decisions remain under the discretion of the healthcare provider.

1
 FIGURE 1A. CLASSIFICATION OF CASES
1 2 3 4
Patient with ARI >60 y/o,
with or without OR with
Y Suspect Case
b Refer to higher
fever in the past comorbids (Moderate to
OR with severe facility
c Severe)
14 days?a symptoms

N 5 6

Exposed by
traveld by Y Suspect Case
residencee, (Mild)
or contactf?
N 7 8 9

Non-COVID ARI COVID Test Y

(Usual Care) Do RT-PCR Test
available?

N 10 11 12
FOOTNOTES
Y
See Figure 1B
aAcute Respiratory Illness (ARI) Positive RT- Confirmed Case
for Contact
Flu-like symptoms (cough, colds, sore throat, body malaise, fatigue, fever) PCR result? (Mild)
Tracing
bComorbids – adults with an underlying health condition listed below:
- Chronic lung disease N 13 14
- Chronic heart disease
- Chronic kidney disease
Negative
- Chronic liver disease Y Suspect case
- Chronic neurological conditions RT-PCR
(Mild)
- Diabetes result?
- Problems with the spleen
- Weakened immune system such as HIV or AIDS, or medicines such as steroid N 15
tablets or chemotherapy
- Morbid obesity (BMI > 40)

cSevere Symptoms: Inconclusive

For adults and adolescents: any of the following: Results
- altered mental state
- shortness of breath
- SpO2 <94%, respiratory rate >30/min 16 17
- systolic blood pressure of <90mmHg See Figure
- other signs of shock or complications 1C for
Probable Caseg
Community
For children: cough or difficulty in breathing, plus at least one of the following: (Mild) Quarantine
- central cyanosis or SpO2 <90%
- severe respiratory distress (e.g. grunting, chest indrawing) Protocol
- signs of pneumonia with a general danger sign: inability to breastfeed or drink,
lethargy/unconsciousness, or convulsions
Other signs of pneumonia may be present: fast breathing (in breaths/min):
<2 months: >60; 2-11 months: >50; 1-5 years: >40

dExposure by travel
Travel from a country/area where there is sustained community level transmission
eExposure by residence
Lives in an LGU where there is sustained community level transmission

fExposure by contact
1. Providing direct care to suspect, probable, or confirmed COVID-19 patients
without using proper PPE (i.e. healthcare workers);
2. Face-to-face contact with a probable or confirmed case within 1 meter and for
more than 15 minutes;
3. Direct physical contact with a probable or confirmed case; OR
4. Other situations as indicated by local risk assessments
gProbable Case
Proceed to box 10 if repeat test becomes possible/available
2
FIGURE 1B. CONTACT TRACING PROTOCOL

1 FOOTNOTES
Contact aExposure by travel
Exposed by travela, Travel from a country/area where there is sustained community level
residenceb, or transmission
contactc bExposure by residence
Lives in an LGU where there is sustained community level transmission
2
ARI with or cExposure by contact
without
fever in the Y 1. Providing direct care to suspect, probable, or confirmed COVID-19
past 14 patients without using proper PPE (i.e. healthcare workers);
2. Face-to-face contact with a probable or confirmed case within 1
days?
d
meter and for more than 15 minutes;
N 3 3. Direct physical contact with a probable or confirmed case; OR
4. Other situations as indicated by local risk assessments
Household dAcute Respiratory Illness (ARI)
quarantinee and
BHERT Flu-like symptoms (cough, colds, sore throat, body malaise; fatigue,
monitoringf fever)
eHousehold Quarantine – All members of the household (including
4 pets) must strictly stay at home
ARI in the 5
See Figure 1A fBHERT Monitoring
next 14 Y
for Triage & Barangay Health Emergency Response Team (BHERT)
days?d Classification
- Accomplish a Case Identification Form (CIF)
- Ensure monitoring throughout the duration of isolation &
N quarantine
6 - Facilitate home care and basic needs
End monitoring - A daily report shall be forwarded to the Municipality/City
Epidemiology and Surveillance Units (MESU/CESU) which in turn are
and home
forwarded to the Provincial Epidemiology and Surveillance Units
quarantine
(PESU)

3
 FIGURE 1C. COMMUNITY QUARANTINE PROTOCOL

Patient with mild

symptoms and
no risk factors

2 3
FOOTNOTES

Y aSelf-isolation – strict isolation of the patient in a separate room or area

Confirmed Confirmed Case
Case? (Mild) in the household
bHousehold Quarantine – All members of the household (including pets)
N 4 must strictly stay at home
cSituations where household quarantine is difficult
Suspect or
1. Living with vulnerable person (with comorbids or >60y/o)
Probable Case
2. No separate bedroom or bed not >1m away
(Mild)
3. No separate bathroom for patient
4. Not well-ventilated
5 5. No separate utensils and personal things
6. No separate towels for handwashing
Consider self-
isolationa and dBHERT Monitoring
household Barangay Health Emergency Response Team (BHERT)
quarantineb - Accomplish a Case Identification Form (CIF)
- Ensure monitoring throughout the duration of isolation & quarantine
6
- Facilitate home care and basic needs
- A daily report shall be forwarded to the Municipality/City
Household Epidemiology and Surveillance Units (MESU/CESU) which in turn are
Y
quarantine forwarded to the Provincial Epidemiology and Surveillance Units
difficult?c (PESU)
eRepeat Test Negative
N
7 8 - Two consecutive negative tests 24 hours apart is preferred or at least
one negative test prior to discharge
BHERT Community fImprovement of symptoms:
Monitoringd Isolation Unit
- Temp <37.8ºC > 3 days,
- Respiratory symptoms reduced significantly
N 9 10 - CXR shows significant improvement
11
Discharge when
Self-isolationa plus Repeat test repeat test
Y
household available negativee and
quarantineb (RT-PCR)? improved
symptomsf
N
12
Discharge when
symptoms have
improvedf for 7
days

4
 FIGURE 1D. PREGNANT PATIENTS
1

Pregnant Patient

2 3 4
With ARI
With
symptomsa or
Y moderate to Y Refer to higher-level
exposed by
severe ARI facility for
travelb,
symptomse or management
residencec, or
high-riskf?
contactd?
N 5 N 6 7 8 9 10
Facility has
Y Is the facility Y infrastructure Y For imminent
Woman about Do RT-PCR Test if
Usual Care BEmONC for isolation and deliveryg in local
to give birth? available
capable? appropriate facility
PPE?
N N N
11 12 13
14
With other Transfer to higher- See Figure 1E
obstetric or Y level facility for Postpartum Careh on Newborn
medical management if Neonatal Carei Care and
indication? possible Breastfeeding

N
15
See Figure 1A
for
Classification
of Cases
FOOTNOTES - Pre-eclampsia/eclampsia
- Preterm pre-labor rupture of membranes
aAcute Respiratory Illness (ARI) (pPROM)Malpresentations
Flu-like symptoms (cough, colds, sore throat, body - Young primigravid
malaise; fatigue, fever) - Elderly primigravid
- Multifetal pregnancy
bExposure by travel
gImminent Delivery
Travel from a country/area where there is sustained
community level transmission - Admit to a designated isolation area
- Require all personnel in attendance to wear the
cExposure by residence appropriate PPE
Lives in an LGU where there is sustained community level - Require all transport personnel to wear appropriate
transmission PPE to be removed once patient has been transferred
- Delivered by NSD
dExposure by contact - Obtain/verify if the naso-oropharyngeal swab
1. Providing direct care to suspect, probable, or specimens were collected
confirmed COVID-19 patients without using proper hPostpartum Care
PPE (i.e. healthcare workers);
2. Face-to-face contact with a probable or confirmed - Monitor postpartum patient in the same isolation
case within 1 meter and for more than 15 minutes; area by the same delivery team
3. Direct physical contact with a probable or confirmed - Discharge early once stable, if mild case
case; OR - coordinate with RESU for monitoring and surveillance
- Require all transport personnel to wear appropriate
4. Other situations as indicated by local risk assessments
PPE (see Figure 3)
eSevere and Critical – any of the following: iNeonatal Care
- Altered mental state - Institute appropriate neonatal resuscitation measures
- Shortness of breath as necessary
- SpO2 <94% - Render standard newborn care
- Respiratory rate >30/min - Do routine hearing and newborn screening tests prior
- Systolic blood pressure of <90mmHg to discharge when feasible
- Other signs of shock or complications - Manage high-risk infants accordingly. Refer to a
fExamples of High-risk features specialist/subspecialist

- Preterm labor
- Vaginal bleeding
5
 FIGURE 1E. NEWBORN CARE AND BREASTFEEDING
FOOTNOTES
aThis algorithm adapted from DOH Memorandum 2020-0146 reflects decision-making in facilities where COVID-19 diagnostic tests
can be done and results secured expediently.

Since most mothers will present as contact cases, management in each specific situation may depend on the context under which
the mother presents. Separation will depend on availability of isolation rooms or facilities, testing capability, safety of the HCW,
and parents’ preferences.
1
WHO Interim Guidance on the Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is
From Figure
suspected or confirmed (updated Mar 13, 2020), recommends to:
1D on
1. Enable mothers and infants to remain together in skin-to-skin contact
Pregnant
2. Practice rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding.
Patients
3. Constant use of surgical mask for mother and proper handwashing before and after handling her newborn

2 bSeparation of newborn and mother

Newborn of If separation is not feasible in the institution due to resource constraints, health care worker may follow guidelines established by
mother own institution
regardless of cExpressed Milk
COVID status Encourage to express milk and give via clean cup or spoon following strict infection precautions
dAlternative Feeding Options
3
- Available, age-appropriate feeding options (donor breastmilk, preferably pasteurized)
Dry newborn, - Give only when previous efforts to provide breastmilk have been exhausted
clamp/cut cord at - Use hygienically and properly prepared breastmilk substitutes
1 minute eCounselling on Exclusive Breastfeeding with Infection Precautions
A. Exclusive breastfeeding per demand
4 5 B. Positioning and attachment
C. Cough etiquette
D. Proper way of wearing a mask when near her child
Stable Y Consider E. Washing hands before and after contact with the child
newborn? Breastmilk feeding F. How to clean/disinfect contaminated surfaces

N
6 7 8

Transfer to Is mother Y Mother is a

appropriate a possible
Contact
neonatal care unit case?

N
9 10 11 12
1. Separate baby and Are both
Is mother a Mother is a mothera,b mother Y
Y 2. RT-PCR on baby
probable/sus Probable or and
pect case? Suspect Case 3. Try expressed newborn
breastmilkc,d negative?
N N
13 14 15 16 17
1. Separate baby and Only the Continue separation;
Is mother Y mothera,b mother or Provide expressed
Mother is a Y
a possible 2. RT-PCR on baby only the milkc
case? Confirmed Case 3. Try expressed newborn is If not possible, other
breastmilkc,d positive? feeding optionsd
N N
18 19 20 21

May room in; Give Newborn Both mother and May room in; Give
Y counseling on exclusive
counseling on exclusive tested newborn are
breastfeeding positive? breastfeeding with
Confirmed Cases infection precautionse

N
22
Continue separation;
Provide expressed
milkc
If not possible, other
feeding optionsd
6
 REFERENCES

De los Reyes, MA, et al. (2020). Clinical Practice Guidelines for Sepsis and Septic Shock in
the Philippines 2020 Full Manuscript. Philippine Society for Microbiology and
Infectious Disease

Department of Health. (2020). Reiteration of the Guidelines on the Disposal and Shipment
of the Remains of Confirmed Cases of 2019 Novel Coronavirus Acute Respiratory
Disease (2019-nCoV ARD). Department Circular No 2020-0047

Liu Y, Yan LM, Wan L, Xiang TX, Le A, Liu JM, Peiris M, Poon LM, Zhang W. (2020) Viral
dynamics in mild and severe cases of COVID-19. Lancet Infectious Diseases 2020

Philippine Obstetrical and Gynecological Society (Foundation) Inc., et al. (2020).

Algorithm on Management of Pregnant PUI/Confirmed COVID-19 Patient

Philippine Society for Microbiology and Infectious Disease. (2020). Interim Guidelines on
the Clinical Management of Adult Patients with Suspected or Confirmed COVID-19
Infection 2.0

Philippine Society of Public Health Physicians. (2020). Recommendation on Community-

Based Management of COVID-19 (v3)

World Health Organization. (2020). Rational use of personal protective equipment (PPE)
for coronavirus disease (COVID-19)