University of Santo Tomas​

Department of Pharmacy
Doctor of Pharmacy

SMALL GROUP DISCUSSION

Group III: Ayunayun, Palomo, Policarpio, Rozen, Talaga, Villamor

Outline of Discussion on COVID-19 Management in the Clinical Setting

I. Introduction: COVID 19 Pandemic ​(00:01-10:08)

a. Current COVID-19 statistics in the Philippines
total cases: 238, 727

b. Current COVID-19 statistics Worldwide

total cases: 27, 486, 277

II. Classification/ Triaging & Referral of COVID-19 Patients

a. Previous Algorithm for Triage of Patient with Possible COVID-19
Infection in healthcare facilities in the Philippines ​(10:09-13:15)

​ a.1 Person under Monitoring (PUM)

● No Symptoms
● Require 14 days home quarantine
● No testing

a.2 Person under Investigation (PUI)

● With symptoms COVID-19 infection
● Required testing
● Refer to RESU (if refused admission)
● Mild symptoms (can be sent home after testing, instruct
about home quarantine)

b. New COVID-19 Classification in the Philippines ​(13:16-17:19)

● Suspect- ​with COVID-19 symptoms plus:
○ Traveled or lived in a place where there are positive cases,
local transmission of COVID-19 (for the last 14 days before
symptoms persists)
○ Had a close contact with a person who is considered to be
a probable, or confirmed case (for the last 14 days before
symptoms persists)

● Probable- suspected case; RTPCR test Underdetermined and not

done in an officially accredited laboratory

● Confirmed​- RT-PCR test positive for COVID-19 conducted from an

accredited laboratory
Classification
Old New

neither PUI or PUM Non- COVID case

PUI- mild, severe and critical
has not been Suspect

tested, for testing, or testing not performed

PUI- inconclusive results or test done by an Probable

unofficial laboratory

COVID-19 positive Confirmed

Frequently asked questions: ​(17:20-25:30)

How do suspect patients get tested for Referred to level 2 or 3 hospitals for
COVID-19? nasopharyngeal or oropharyngeal swab.

Is the testing free? Testing is free only for suspect cases. For
work purposes, testing can be done in
accredited hospitals with testing centers but
fee is required.

While waiting for the test result, will a Persons with mild symptoms are required
person be allowed to go home? for a 14-day strict home quarantine.
Patients with severe symptoms are
required for hospitalization.

Is hospitalization needed for suspect Mild and asymptomatic cases do not

patients? hospital admission; 14-day home
quarantine is enough but continue
monitoring.

Can you consider a patient as suspect if Know first the cause of disease and if local
manifesting Influenza like-illness but transmission is present in the community.
without travel history? Patient can be considered suspect if he/she
had contact with a confirmed or probable
case in the last two days prior to onset of
illness.

What happens if the patient refuses to The patient’s information will be recorded
be tested for COVID-19? and reported as a PROBABLE case to
DOH. He/she will be required to do a
14-day quarantine, with any symptoms
being treated accordingly
 What happens when there is no Patient will now be classified as a probable
available testing? case. Refer to other accredited hospitals
that can perform the test

(Philippines) COVID-19 Patient Pathway ​(30:42-33:22)

● DOH together with DILG mandates the creation of a responding team for
managing COVID-19 in each local government unit.
● Each household or individual may notify the Barangay Health Emergency
Respond Team (BHERT) for assessment if COVID-19 symptoms are manifested
by a certain individual.
● Probable, suspect and PUM patients with mild symptoms are referred to a
Temporary Treatment Monitoring Facility (TTMF) - “Ligtas COVID-19 Centers”
with individual rooms and toilets.
● Confirmed patients with mild symptoms are referred to TTMF with
cohorting-”Mega Ligtas COVID-19 Centers (PICC).
● Confirmed,probable and suspect patients with severe symptoms are referred to
COVID-19 referral hospitals such as Regional hospitals.
● Recovering confirmed patients may be transferred to COVID-level 1 or step down
hospitals.

c. WHO COVID-19 Case definition/Classification ​(33:23-38:40)

Suspect Probable Confirmed

Clinical Criteria: → meets clinical and → ​laboratory confirmation of

→ acute onset of fever & cough or any epidemiological criteria & COVID-19 infection
of 3 or more: is a contact of probable irrespective of clinical signs
or confirmed case and symptoms
fever, cough, gen.
weakness/fatigue,HA, myalgia, sore → chest imaging
throat, coryza, dyspnea,anorexia/N&V, suggestive of COVID-19
diarrhea, altered mental status
→ recent onset of
Epidemiological Criteria: anosmia/ ageusia
→ In an area with high risk of
transmission within 14 days prior to → death not otherwise
symptoms onset or explained
travel to an area with community
transmission or working in a health
care setting including within health
facilities or within community.
 d. WHO Care Pathway ​(38:40-42-25)

Purpose: educate community primary care and hospital-based providers on how to

evaluate and diagnose patients with a possible COVID-19 infection
Recommended: established at local, regional, and national levels

● All suspected cases need testing.

● Negative: required to remain in the pathway
● If testing is not available, the person will become a probable case and will still be
taken care of in the pathway. Released based on symptomatic classification:
Asymptomatic​: 10 days after testing positive
Symptomatic​: 10 days after symptom onset, plus at least 3 days without symptoms

Management of close contacts ​(42:26-47:59)

● Close contact is a person who looked after a confirmed COVID-19 patient without
proper personal protective equipment and had direct contact, lived, worked,
transacted, or travelled in close proximity (less than 1 meter) with a confirmed
COVID-19 case.

CLOSE CONTACTS

Symptomatic Asymptomatic

Suspect Not a suspect Non-HW HW low Risk HW High Risk

Exposure Exposure

+health facility +14-day strict +14-day strict +self-reporting +14-day strict

isolation home home quarantine for next 14 days home quarantine
+lab confirmatory quarantine +monitoring -lab confirmatory +monitoring
test +monitoring -lab confirmatory test +lab confirmatory
-lab test test
confirmatory
test

e. Local and International Algorithm for COVID 19 Referral and Triage

(48:53:57)

● Assessment of symptoms is necessary before the referral to a primary or

second healthcare facility
● Patient will be classified as ​mild case if the criteria for referral was not
fulfilled and if patient has no risk factor for severe disease. Patients will have
to undergo community care isolation/home quarantine.
● moderate and severe cases will be refer to covid 19 hospital and will
require to have a covid-19 test, blood test and imaging (CXR/CT)
● For ICU patients, consider early intubation and renal replacement therapy
● If patient did not meet the ICU admission criteria, patient will have to be
isolated in an inpatient admission and care at tertiary hospital
*​Modifications from Local Guidelines

Difference

Philippines - Triaging and Referral WHO-Triaging and Referral

● DOH COVID Hotlines ● Drive through swab testing

● Criteria for referral to hospital ● Criteria for referral to hospital
-Oxygen Saturation ≤92% -Oxygen Saturation <94%

*​Case Investigation and Contact Tracing Process

● Tracing the contacts of confirmed cases, testing them for infection and treating
the infected interrupts ongoing transmission and reduces the spread of the
infection in the community.
● Close contact and monitoring team facilitates the case investigation and contact
tracing process.

III. COVID-19 Management Algorithm

a. Management Algorithm of Patients with Probable or Confirmed
COVID-19 ​(58:15-59:37)
a.1 Mild
a.2 Moderate
a.3 Severe
a.4 Critical

Mild symptomatic patients meeting the case

definition for Covid-19 without the
presence of viral pneumonia or hypoxia

Moderate adolescent or adult with clinical signs of

non-severe pneumonia; child with
non-severe pneumonia

Severe adolescent or adult with clinical signs of

pneumonia plus severe respiratory
Critical distress or RR of >30 breaths/min.; child
with clinical signs of pneumonia with
central cyanosis or severe respiratory
distress
 b. WHO/CDC Management of Patients with COVID-19 ​(1:00:03-1:02:32)

● Mild symptoms ​of COVID-19- Isolate to contain virus transmission. Done at any
designated COVID-19 health facility, community facility or at home
(strict-isolation).
● Moderate COVID-19 Pneumonia treatment ​Patients with a moderate illness
may not require emergency interventions or hospitalization; however, in a case to
case basisLocation of isolation (health facility, community facility, at home)
● Severe COVID-19: severe pneumonia ​All areas where severe patients may be
cared for should be equipped with pulse oximetry, functioning oxygen systems
and disposable, single-use, oxygen-delivering interfaces (nasal cannula, venturi
masks, and mask with reservoir bags)

● Management of critical COVID-19:

Hemodynamic support

- Recommends ​Norepinephrine​ as the first-choice vasopressor

- For adults with COVID-19 and refractory shock, using ​low-dose corticosteroid
therapy (“shock-reversal”) over no corticosteroid is recommended

Ventilatory support

- For adults with COVID-19 and acute hypoxemic respiratory failure despite
conventional oxygen therapy, ​high-flow nasal cannula (HFNC) oxygen ​over
noninvasive positive pressure ventilation (NIPPV) is recommended

Recommendations

Endotracheal intubation not closely monitored trial of NIPPV​ for adults with COVID-19
required/ Acute hypoxemic
respiratory failure HFNC is not
available

Receiving supplemental Closely monitor for worsening respiratory status and that
oxygen intubation

Persistent hypoxemia despite consider a trial of ​awake prone positioning ​to improve
increasing supplemental oxygenation
oxygen requirements in whom
endotracheal intubation is not
otherwise indicated,
 Recommendations

Mechanically ventilated low tidal volume (VT) ventilation (VT 4–8

adults/ ARDS mL/kg of predicted body weight) over
higher tidal volumes (VT >8 mL/kg)

Mechanically ventilated inhaled pulmonary vasodilator as a

adults, severe rescue therapy. if no rapid improvement in
ARDS+hypoxemia oxygenation is observed, the treatment
should be tapered off

*​ Infection and Prevention Control

● Implement Telehealth and Nurse-Directed Triage Protocols

● Screen and Triage Everyone Entering a Healthcare Facility for Signs and
Symptoms of COVID-19
● Re-evaluate admitted patients for signs and symptoms of COVID-19
● Implement Universal Source Control Measures
● Encourage Physical Distancing
● Implement Universal Use of Personal Protective Equipment
● Consider Performing Targeted SARS-CoV-2 Testing of Patients Without Signs or
Symptoms of COVID-19
● Consider if elective procedures, surgeries, and non-urgent outpatient visits
should be postponed in certain circumstances.
● Optimize the Use of Engineering Controls and Indoor Air Quality
● Create a Process to Respond to SARS-CoV-2 Exposures Among HCP and
others

Local and International Algorithm for COVID-19 Pregnant and Neonatal Care
(1:04:18-1:21:13)

c. Local and International Algorithm for COVID-19 ​Pregnant Women

● It is recommended that suspected and confirmed COVID 19 pregnant patients

have to undergo obstetric condition assessment may or may not be in labor, or in
an imminent delivery
● required to collect swab test before delivery
● It is recommended to perform Cesarean delivery for patient with severe
respiratory failure
● Monitor postpartum patient in the same area and with the same COVID 19
delivery team
● Extending PPEs for aerosol protection during the delivery
 d. Local and International Algorithm for COVID 19​ Neonatal care

● Temporary separation of the baby from the mother must be done until both
COVID 19 results are available and are negative.
● Contact precautions, room isolation and monitoring of maternal and infant is
recommended
● The patient may choose for feeding options such as breastfeeding, pump milk, or
formula but has to maintain contact precautions in isolation room

*​Precautions of ​Immunocompromised and Elderly​ COVID 19 Patients

IMMUNOCOMPROMISED
● Continue any recommended medicines or treatments and follow the advice of the
healthcare provider.
● Do not stop taking your medicines without talking to your healthcare provider.
● Make sure that the patient have at least a 30-day supply of your medicines
ELDERLY
● Standard precautionary measures are highly recommended
● Continue taking the prescribed medicines
● Restrict visitors as much as possible
● Require or recommend visitors wear masks over their nose and mouth, if visitors
are allowed

e. Local and International Criteria for Discharge and Recovery of COVID 19

Patients ​(1:24:26-1:30:54)
● LOCAL:
○ Recovered​:still undergo strict quarantine for 14 days
○ Symptomatic: after onset symptoms + at least 3 days no symptoms +
completed 14 days self-isolation= clinically recovered
○ Asymptomatic (Positive in RT-PCR): no symptoms for 14 days +
completed 14 days self-isolation = clinically recovered
● INT’L:
○ Asymptomatic: no testing required or in some countries, they require
RT-PCR 2 times, 24 hrs interval.

*​RT-PCR Testing

Specific Guidelines

For Symptomatic Patients

A. If IgM negative, collect samples for RT-PCR testing

​a.1 If RT—PCR negative, the patient is not a COVID-l9 case but has to complete
the 14-day quarantine.
a.2 If RT-PCR positive, the patient is a confirmed COVID-l9 case and shall be
treated and undergo isolation accordingly.
a.3 If RT—PCR testing is not available, isolate the patient for 14 days or until
asymptomatic, whichever is longer.
​B. If IgM positive, the patient is a probable COVID-19 case. Collect swab for
RT-PCR testing.
b1. If RT—PCR positive, the patient is a confirmed COVID-l9 case and shall be
treated and undergo isolation accordingly.
b2. If RT—PCR negative, the patient has to complete the 14-day quarantine or until
asymptomatic whichever is longer and repeat rapid antibody-based test once
asymptomatic.
​ For Asymptomatic Patients
1. 14 days of quarantine from the date of last contact with the confirmed or probable
COVID-l9 case.
2. Asymptomatic close contacts of confirmed or probable COVID-19 symptoms may be
tested using RT-PCR at the discretion of the contact tracing team
3. can be released from quarantine after 14 days as long as the patient remains
asymptomatic for the entire duration of the quarantine, even without testing or test
results.

f. Local and International Guidelines on Proper Handling of the remains of

Suspect, Probable and Confirmed COVID19 Patients ​(1:30:55-1:37:42)

1. Burial and Cremation shall be done within 12 hrs after death. (but should be in
accordance with the person’s religion)
2. Practice Proper Hygiene and standard precautions to the staff
3. Transportation provided (funeral home to burial site)
4. Avoid Large gathering
5. Buried​:
a. only adult members are allowed in the burial
b. durable, airtight and sealed metal casket. (if islamic faith, double cadaver
bag with <150micrometer thick)
c. viewing of remains is not permitted
Cremated:
a. size of fine sand or ashes and packed in a cremains container
b. Cremains shall be in a container (min. of 0.0049 cubic meter) made of
polyethylene with liner bag (5 ml plastic), locking tie and identification
label.

IV. Takeaways​ ​(1:38:43-1:45:32)

● No one is prepared for the pandemic. Everyone must be responsible with
their actions to prevent the spread of the virus.
 ● When it comes to interviews we must be truthful in disclosing our travel
history and past medical history otherwise we might put the health workers
at higher risk of contracting the virus.
● Filipinos must share a sense of civic purpose to achieve an overall
compliance because no matter how streamline the protocols are, if the
citizens do not cooperate, the guidelines will serve no purpose.
● A unified effort is necessary to combat the virus.

legend
(*) recommendations from other groups