2021-06-01-COVID-19-Algo-ver-4.0 2

ALGORITHMS FOR COVID-19
NAVIGATION TABLE
Triage and Management Discharge and

Testing Reintegration
Asymptomatic patients
- No symptoms but travelling from or living in areas Figure A1 Figure A2 Figure A3
with community transmission
COVID-19 Contacts
- Close contacts of confirmed, probable or Figure B1 Figure B2 Figure B3
suspected cases;
Mild COVID-19 (suspected or confirmed)
- Symptoms present1,with no risk factors2 and no Figure C1 Figure C2 Figure C3
signs of pneumonia3
Moderate COVID-19 (suspected or confirmed)
- Symptoms present1 plus risk factors2 , OR signs Figure D1 Figure D2 Figure D3
of pneumonia
Severe COVID-19 (suspected or confirmed)
- Symptoms present plus signs of respiratory Figure E1 Figure E2 Figure E3
failure4
Critical COVID-19 (suspected or confirmed)
- Symptoms present plus deteriorating vital signs5 Figure F1 Figure F2 Figure F3
Other Guidelines
Emergency Department and Transport Figure G1-5
Pregnancy (H1), Labor (H2) and Newborn (H3) Figure H1 Figure H2 Figure H3
Use of Personal Protective Equipment (PPE) Figure I
Advanced Care Planning Figure J
End-of-life Care Figure K
Post-mortem Care Post-Mortem Care Guidelines
1 Symptoms: cough OR sore throat OR fever OR diarrhea OR loss of taste or smell

2Risk factors: age > 60 OR comorbid conditions like chronic lung disease, chronic heart disease, hypertension,
chronic kidney disease, chronic neurological conditions, diabetes, problems with the spleen, weakened immune
system such as HIVm AUDS or medicines (steroid, chemotherapy), morbid obesity (BMI > 40)
3 Signs of pneumonia: difficulty of breathing, crackles on PE, Xray findings.
4 Respiratory failure: difficulty of breathing OR O2 saturation < 94 OR RR > 30
5 Hypotension, shock, diminished sensorium, ARDS, sepsis, or end organ failure
Figure A1-A3
ASYMPTOMATIC PATIENTS
2
Figure A1 – Asymptomatic COVID-19 (Triage and Evaluation)
Return to Navigation
1
Asymptomatic
patient referred
for COVID-19
clearance
2
Arrived with a Y
positive RT-
PCR result?
N
3 4
Exposure by See Figure B2
close contact Y Management of
with a known Close Contact
case?
N
5
Exposure by Y
travel from
area of high
transmission?
N
6 7 8 9 10
Are there Enough
Exposure by Fulfills any of
sufficient RT- human
residence in a the ff? Y Y
Y Y PCR tests to resources for RT-PCR on Day 5-7
community - elderly >60 cover for additional
with high
after exposure
- with
symptomatics contact
transmission? comorbidity ? tracing?
N N N N
11 12 13
Confirmed
Adhere to Positive RT- Y COVID-19
minimum public PCR result? Asymptomatic
health standards
Case
N
14
15
Complete 14-day See Figure A2
quarantine from Management of
last day of Asymptomatic
exposure (Day 0) Cases
Figure A2 – Asymptomatic COVID-19 (Management)
From Figure A1
2
Confirmed
COVID-19
Asymptomatic
Case
3
Ensure that
contact tracing has
been initiated
through
CESU/MESU
4 5 6 7
Available Can
separate room adequately
Does the
in the Y monitor and Y patient prefer
Y Quarantine at
household and treat patient’s
to stay in at Homea
with proper clinical
home?
air evolution at
ventilation? home?
N N N 8
9 10
11
Quarantine at Begin Reclassify.
LIGTAS COVID Monitoringc of Patient w/ Y
See Navigation
Centerb symptomsd?
cases Table
N
12
13
End monitoring See Figure A3
and home Discharge and
isolation Reintegration
FOOTNOTES
aSelf-quarantine at Home - Members of the same household who have been
exposed must strictly separate from non-exposed members and stay at home
per LGU protocol.
b
LIGTAs COVID Center – Contacts shall be provided with individual isolation
rooms separate from those who are symptomatic. In community-based isolation,
special consideration must be attributed to individuals requiring assistance with
activities of daily living (e.g., elderly living alone, young children, persons with
disabilities, mothers of young infants)
cMonitoring by Barangay Health Emergency Response Team (BHERT) for home
quarantine:
- Patient advises BHERT and Primary Care Provider of exposure status (self-
reporting)
- Accomplish a Case Investigation Form (CIF) by BHERT and/ore Primary Care
Provider
- Ensure daily monitoring throughout the duration of quarantine
- Faciliate home care and basic need
- A daily report shall be forwarded to the Municipality/City Epidemiology and
Surveillance Units (MESU/CESU) which in turn are forwarded to the
Provincial Epidemiology and Surveillance Units (PESU)
- Proper advice is given on how to do home quarantine, and to do minimum
health standard precautions to the exposed patient
d
COVID-19 common signs and symptoms – fever, cough, general
weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia,
nausea, vomiting, diarrhea, altered mental status, anosmia, ageusia/dysgeusia
4
Figure A3 – Asymptomatic COVID-19 (Discharge and Reintegration)
From Figure A2
Asymptomatic
Confirmed Case
3
Complete 10-day
quarantine from
last day of
exposure (Day 0)
Is the patient Y
immuno-
compromiseda?
N
5
6 7 8 9
Is the
patient a Y RT-PCR test Y Repeat
Y Refer to Infectious
healthcare Do RT-PCR RT-PCR
available? Disease specialist
worker? Positive?
N N N
10 11 12
Recovered May return to

Discharge from Y Asymptomatic worke. No further
isolationb,c Confirmed Case tests necessary
FOOTNOTES
a
Immunocompromised individuals are patients
• On chemotherapy for cancer
• Untreated HIV infection with CD4 T-lymphocyte count <200
• Combined immunodeficiency disorder
• Taking prednisone 20 mg/day for more than 14 days
bA repeat negative RT-PCR test is no longer needed for discharge of immunocompetent patient with suspect,
probable or confirmed COVID-19 regardless of severity.
c
Health management of discharged patients
• Close follow-up is still required
• His/her place of residence and address should be recorded and the local government unit informed.
Patient instructions:
• Continue to wear mask, practice cough etiquette and maintain physical distancing at home
• If fever and/or respiratory symptoms emerge, the primary health care facility should assist in sending them to the
designated medical institutions in the area for assessment and treatment. This should be reported to the
surveillance units of the Department of Health.
dRefer to workplace guidelines

1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)
2. DOH Workplace Handbook as of September 30, 2020
Figure B1-B3
CONTACTS
6
Figure B1 – Contacts (Triage and Evaluation)
1
a
Close Contact of
a COVID-19
probable,
confirmed in the
past 14 days
2 3 4 5
Option to test IF
Fulfils ANY Are there sufficient RT-PCR or Rapid
Enough human
of the ff: Y RT-PCR/Rapid Y resources for Y Antigen test is
- Elderly (>60 y/o) Antigen test to
additional contact accessible and
- with comorbidity cover for
tracing? affordable at Day
asymptomatic?
5-7
N N N
6 7
Positive RT- Confirmed
PCR Y COVID-19
result/Rapid Asymptomatic
Antigen Test? Case
N
8 9
Refer to Refer to A1:
Figure B2: Triage and
Evaluation of
Management
of Contacts Asymptomatic
Case
FOOTNOTES
aClose Contact: failed in two or more of the following exposures to a probable or confirmed case in
the past 14 days: poorly ventilated indoor area, distance < 1 meter, unprotected/no PPE, exposure
>15 mins. Examples: living with or caring for a COVID-19 patient
bCOVID-19 common signs and symptoms – fever, cough, general weakness/fatigue, headache,
myalgia, sore throat, coryza, dyspnea, anorexia, nausea, vomiting, diarrhea, altered mental status,
anosmia, ageusia/dysgeusia
7
Figure B2 – Contacts (Management)
1
From Figure A1
OR
Figure B1
Exposure by
travel or Close
Contact
3 4 5 6
Available Can
separate room adequately
Does the
in the Y monitor and Y patient prefer
Y Quarantine at
household and treat patient’s
to stay in at Homea
with proper clinical
home?
air evolution at
ventilation? home?
N N N
7 8
Quarantine at Begin
LIGTAS COVID Monitoringc of
Centerb cases
9 10 11
COVID-19
common signs Reclassify.
Y COVD See
and symptoms Navigation
Suspect Case
in the next 14 Table
days?d
N
12
Complete
quarantine and
continue
monitoring
13
Refer to
Figure B3:
Discharge and
reintegration
of contacts
FOOTNOTES
aSelf-quarantine at Home - Members of the same household who have been exposed must strictly separate from non-exposed members and
stay at home per LGU protocol.
bLIGTAs COVID Center – Contacts shall be provided with individual isolation rooms separate from those who are symptomatic. In community-
based isolation, special consideration must be attributed to individuals requiring assistance with activities of daily living (e.g., elderly living
alone, young children, persons with disabilities, mothers of young infants)
cMonitoring by Barangay Health Emergency Response Team (BHERT) for home quarantine:
- Patient advises BHERT and Primary Care Provider of exposure status (self-reporting)
- Accomplish a Case Investigation Form (CIF) by BHERT and/ore Primary Care Provider
- Facilitate home care and basic need
- A daily report shall be forwarded to the Municipality/City Epidemiology and Surveillance Units (MESU/CESU) which in turn are forwarded to
the Provincial Epidemiology and Surveillance Units (PESU)
- Proper advice is given on how to do home quarantine, and to do minimum health standard precautions to the exposed patient
dCOVID-19 common signs and symptoms – fever, cough, general weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia,
nausea, vomiting, diarrhea, altered mental status, anosmia, ageusia/dysgeusia 8
Figure B3 – Contacts (Discharge and Reintegration)
From Figure B2
Close Contact
under quarantine
End monitoring
and home
quarantine after 14
days
Discharge
May return to
worka
FOOTNOTES
NOTE: RT-PCR tests, rapid antibody tests, and rapid antigen tests are NOT recommended for work clearance.
a Refer to workplace guidelines
1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)

9
FIGURE C1-C3
MILD COVID-19
10
Figure C1 – Mild COVID-19 (Triage and Evaluation)
1 Return to Navigation
MILD
Suspecta
2 3
RT-PCR test
available in a Y
Y
nationally Do RT-PCR test
accredited
laboratory?
N 4 5 6 7
Rapid antigen Y Y Y MILD

test available? Do Rapid Ag Test Positive?
Confirmed
N N 8
Previous
contactb or Y
linked to a
clusterc of
cases
N 9
Recent
anosmia or
ageusia
Y
without
identified
cause?
N 10 11
IF chest imaging
Y MILD Refer to Figure
was done, are
findingsd suggestive Probable C2: Mild
of COVID-19? Management
12 13
N
Usual precautions
Non-COVID ARI
and care
aSUSPECT
I. A person who meets the clinical AND epidemiological criteria:
1. Clinical criteria:
• Acute onset of fever AND cough; OR
bCONTACT
• Acute onset of ANY THREE OR MORE of the following signs or
symptoms: fever, cough, general weakness/fatigue, headache, • Failed in two or more of the following exposures to a probable or
myalgia, sore throat, coryza, dyspnea, confirmed case in the past 14 days: poorly ventilated indoor
anorexia/nausea/vomiting, diarrhea, altered mental status. area, distance < 1 meter, unprotected/no PPE, exposure >15
AND mins
2. Epidemiological criteria: • Examples: living with or caring for a COVID-19 patient
• Residing or working in an area with a high risk of transmission C
of the virus: for example, closed residential settings and A cluster is a group of symptomatic individuals linked by time,
humanitarian settings, such as camp and camp-like settings for geographic location and common exposures, containing at least one RT-
displaced persons, anytime within 14 days prior to symptom PCR confirmed case OR at least two epidemiologically linked,
onset; OR symptomatic {meeting clinical criteria in footnote b) persons with
• Residing in or travel to an area with community transmission positive Rapid Antigen Test.
anytime within 14 days prior to symptom onset; OR d
• Working in a health setting, including within health facilities and Typical chest imaging findings of COVID-19:
within households, anytime within 14 days prior to symptom 1. Chest radiography - hazy opacities, often rounded in morphology, with
onset. peripheral and lower lung distribution;
2. Chest CT - multiple bilateral ground glass opacities, often rounded in
II. A patient with severe acute respiratory illness (SARI: acute morphology, with peripheral and lower lung distribution;
3. Lung ultrasound - thickened pleural lines, B lines, consolidative
respiratory infection with history of fever or measured fever of > 38
patterns with or without air bronchograms. 11
degree Celsius; and cough; with onset within the last 10 days; and
which requires hospitalization)
Figure C2 – Mild COVID-19 (Management)
1 2 Return to Navigation
MILD
From Figure C1 Probable/
Confirmed
3
Ensure that
contact tracing has
been initiated thru
CESU/MESU
4 5 6 7
Available Can adequately
separate room monitor and Does the
in the Y treat patient’s Y patient prefer Y
household and Isolate at Homea
clinical to stay in at
with proper air evolution at home?
ventilation? home?
N N N
8 9
Isolate at LIGTAS Quarantinec the

COVID Centerb entire household
a Isolateat home 10
Patient in home isolation must stay separate from other household Identify close
members who are also in home quarantine. Caregivers must wear contacts . Refer
mask properly when attending to patient, observe hand hygiene, to B1: Contacts
and limit duration of contact. Triage
b LIGTAS COVID Center - Contacts shall be provided with

individual isolation rooms, separate from those who are 11
symptomatic. In community-based isolation, special consideration Begin Monitoring d
must be afforded to individuals requiring assistance with activities of cases
of daily living e.g. elderly living alone, young children, persons with
disabilities, mothers with young infants, etc.
c Home Quarantine - All members of the household must strictly Provide 12

stay at home per LGU protocol. symptomatic
treatment. No
d Monitoring antibiotic needed.
by Barangay Health Emergency Response Team No prophylaxis.
(BHERT) for home quarantine:
- Patient advises BHERT and Primary Care Provider of exposure
13 14
status (self-reporting)
- Accomplish a Case Investigation Form (CIF) (by BHERT and/or Worsening Y Reclassify.
signs and Return to
Primary Care Provider
symptoms? navigation table
- Facilitate home care and basic needs N
- A daily report shall be forwarded to the Municipality/City 15
16
Epidemiology and Surveillance Units (MESU/CESU) which in turn Improvinge Refer to
are forwarded to the Provincial Epidemiology and Surveillance MILD Figure C3
Units (PESU) Probable/ Discharge
- Proper advice is given on how to do home quarantine, and to do Confirmed
minimum health standard precautions to the exposed patient
e Improvement of clinical status:

- No fever for at least 24 hours without antipyretics
- Respiratory symptoms reduced significantly
- CXR shows significant improvement if available
Figure C3 – Mild COVID-19 (Discharge and Reintegration)
FOOTNOTES
aImprovement of clinical status

• No fever or use of antipyretic for at least 3 days
1 • Respiratory symptoms reduced significantly
• CXR (if available) shows significant improvement
From Figure C2 b
Immunocompromised individuals are patients
• Untreated HIV infection with CD4 T-lymphocyte count <200
2 • Taking prednisone 20 mg/day for more than 14 days
c
Improving MILD A repeat negative RT-PCR test is no longer needed for discharge of
Probable/ immunocompetent patient with suspect, probable or confirmed COVID-19
Confirmed regardless of severity.
dHealth management of discharged patients
3 • Close follow-up is still required
• His/her place of residence and address should be recorded and the local
government unit informed.
Wait for 10 days
since onset of
• Continue to wear mask, practice cough etiquette and maintain physical
symptoms
distancing at home
• If fever and/or respiratory symptoms recur, the primary health care
4 facility should assist in sending them to the designated medical
institutions in the area for assessment and treatment. This should be
Wait for clinical reported to the surveillance units of the Department of Health.
improvementa
AND
eReferto workplace guidelines
no antipyretic use
for ≥24 hours? 1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)
5
Is the patient Y
Immuno-
compromisedb?
N 7 8
6 9 10
Is the
patient a Y RT-PCR test Y RT-PCR Y Refer to Infectious
Do RT-PCR test Disease specialist
healthcare available? Positive?
worker?
N N N
11 12 13
Recovered MILD May return to

Discharge from Y
Probable/ worke. No further
isolationc,d
Confirmed tests necessary.
FIGURE D1-D3
MODERATE COVID-19
14
Figure D1 - Moderate COVID-19 (Triage and Evaluation)
MODERATE
Suspect Case
3 4
2
Admit the patient a HESU to inform
With pneumonia Inform and CESU/MESU so
Y
or other indications prepare patient for that contact
for admission? transport tracing can be
(See Figure G) anticipated.
N
5 6 7 8
Isolate and Test available
May opt NOT to facilitate testing. in a nationally Y
admit (e.g. during Inform close Do RT-PCR test
accredited
a surge) contacts. laboratory?
N
9 10 11
12
Positive
Rapid Antigen test Y RT-PCR or Y
Do Antigen test MODERATE
available?
Antigen Confirmed
result?
N N
12
Previous contactb Y
or linked to a
clusterc of cases?
FOOTNOTES N
13
a
Administer acute care for the patient while considering Recent Y
admission and service capability. Service capability as basis anosmia or ageusia
for admission can depend on multiple factors including: (1) without
best clinical judgement of the health provider (2) identified cause?
appropriateness of health care facility (3) geographical
N
access to the next higher level facility (4) patient context. 14 15
16
b
Contact: Failed in two or more of the following exposures IF chest imaging
to a probable or confirmed case in the past 14 days: poorly Y See Figure D2.1
was done, are MODERATE
findingsd suggestive for Management
ventilated indoor area, distance < 1 meter, unprotected/no Probable
PPE, exposure >15 mins of COVID-19? of Moderate Cases
Examples: living with or caring for a COVID-19 patient
N
18
c
The cluster should have at least one confirmed case. 17
dTypical chest imaging findings of COVID-19: Usual precautions

Non-COVID ARI
1. Chest radiography - hazy opacities, often rounded in and care
morphology, with peripheral and lower lung distribution;
2. Chest CT - multiple bilateral ground glass opacities, often
rounded in morphology, with peripheral and lower lung
distribution;
3. Lung ultrasound - thickened pleural lines, B lines,
consolidative patterns with or without air bronchograms.
Figure D2.1 – Moderate COVID-19 (Outpatient Management)
1
From Figure D1
FOOTNOTES
2 aAdminister acute care for the patient while considering admission and service capability. Service capability
as basis for admission can depend on multiple factors including: (1) best clinical judgement of the health
MODERATE provider (2) appropriateness of health care facility (3) geographical access to the next higher level facility (4)
patient context.
Confirmed/
Probable bIsolate at home Patient in home isolation must stay separate from other household members who are also
in home quarantine. Caregivers must wear mask properly when attending to patient, observe hand hygiene,
and limit duration of contact.
3 4 5
Confirmed/ cLIGTAS COVID Center - Contacts shall be provided with individual isolation rooms, separate from those who
Was the Probable See Figure D2.2 for are symptomatic. In community-based isolation, special consideration must be afforded to individuals
patient
Y Inpatient Management requiring assistance with activities of daily living e.g. elderly living alone, young children, persons with
MODERATE
of Moderate Cases disabilities, mothers with young infants, etc.
admitted?a COVID-19
(Inpatient) d Home Quarantine - All members of the household must strictly stay at home per LGU protocol.
N
6 eMonitoring by Barangay Health Emergency Response Team (BHERT) for home quarantine:
Confirmed/ - Patient advises BHERT and Primary Care Provider of exposure status (self-reporting)
Probable - Accomplish a Case Investigation Form (CIF) (by BHERT and/or Primary Care Provider
MODERATE - Ensure daily monitoring throughout the duration of quarantine
COVID-19 - Facilitate home care and basic needs
(Outpatient) - A daily report shall be forwarded to the Municipality/City Epidemiology and Surveillance Units (MESU/CESU)
which in turn are forwarded to the Provincial Epidemiology and Surveillance Units (PESU)
7 - Proper advice is given on how to do home quarantine, and to do minimum health standard precautions to
the exposed patient
Ensure that
contact tracing has
been initiated thru
CESU/MESU
8 9 10 11
Available separate Can adequately
Does the patient
room in the household Y monitor and treat Y Y
prefer to stay Isolate at homeb
and with proper patient’s clinical
at home?
air ventilation? evolution at home?
N N N
12 13 16
Quarantine the
Symptomatic treatment
Isolate in LIGTAS entire householdd
No antibiotic needed
COVID Centerc Begin monitoringe
No prophylaxis needed
of cases
17
18
Y Reclassify patient.
Patient worsening?
See Navigation Table
N
19
20
See Figure D3 for
Improvement of Y Discharge and
Clinical Statush Reintegration
of Moderate Cases
Figure D2.2 – Moderate COVID-19 (Inpatient Management)
1
FOOTNOTES
From Figure D2.1 aNeed informed consent BEFORE using COVID-19 investigational drugs &
interventions in trials or compassionate use.
bInvestigationalDrugs For Moderate COVID-19

2
Confirmed/ - Favipiravir
Probable - Remdesivir
MODERATE - Convalescent plasma
COVID-19 cComorbids - Underlying health condition listed below:
(Inpatient)
- Chronic lung disease
- Chronic heart disease or Hypertension
3
- Chronic kidney disease
Continue - Chronic liver disease
supportive - Chronic neurological conditions
therapy. - Diabetes
- Problems with the spleen
- Weakened immune system such as HIV or AIDS, or medicines such as
4 steroid tablets or chemotherapy
- Morbid obesity (BMI > 40)
Consider participation eImprovement of clinical status:
in a clinical triala,b
- Afebrile for at least 24 hours without antipyretics
- CXR shows significant improvement if available
5
Consider
compassionate use
of investigational
Drugsa,b
6
7
Y Reclassify patient.
Patient worsening?
See Navigation Table
N
8
9
See Figure D3 for
Improvement of Discharge and
Clinical Statusd Reintegration
of Moderate Cases
Figure D3 – Moderate COVID-19 (Discharge and Reintegration)
1
FOOTNOTES
From Figure D2.1
OR a
Improvement of clinical status
Figure D2.2
• Respiratory symptoms reduced significantly
2
bImmunocompromised individuals are patients
Improving • On chemotherapy for cancer
MODERATE Case • Untreated HIV infection with CD4 T-lymphocyte count <200
• Taking prednisone 20 mg/day for more than 14 days
3 c
A repeat negative RT-PCR test is no longer needed for discharge of
immunocompetent patient with suspect, probable or confirmed COVID-19
Wait for 10 days regardless of severity.
since onset of dHealth management of discharged patients
symptoms
4
Wait for clinical • Continue to wear mask, practice cough etiquette and maintain physical
improvementa
AND distancing at home
no antipyretic use • If fever and/or respiratory symptoms recur, the primary health care
for ≥24 hours? facility should assist in sending them to the designated medical
5 reported to the surveillance units of the Department of Health.
e
Is the patient Refer to workplace guidelines
Y
Immuno- 1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)
compromisedb? 2. DOH Workplace Handbook as of September 30, 2020
N
6
7 8 9
Is the
patient a Y Repeat
RT-PCR test Y Y Refer to Infectious
healthcare RT-PCR
worker? Positive?
N N N
11 10 12
11

Discharge from Y MODERATE worke. No further
isolationc,d Case tests necessary
FIGURE E1-E3
SEVERE COVID-19
19
Figure E1– Severe COVID-19 (Triage and Evaluation)
1
Patient is a
SEVERE
COVID-19
Suspecta
Stabilize patientb
3
See Figure J1
for
Advance Care
Planning
5 6
4 COVID-19 test
See Figure G
available in a Y
Emergency
nationally Do RT-PCR
Department &
accredited
Transport
laboratory?
N
7 8 9
10
Rapid Ag test Y Do Rapid Antigen Positive Y Confirmed
available? Test result? SEVERE COVID-
19
N N
11
Previous
contactc or Y
linked to a
clusterd of
cases?
N
12
Recent
anosmia or ageusia Y
without
identified cause?
N
13 14
15
IF chest imaging
Y See Figure E2
was done, are Probable
e
findings suggestive Management of
Severe COVID-19
of COVID-19? SEVERE COVID-19
N
16 17
Usual precautions
Non-COVID ARI and care
Figure E1– Severe COVID-19 (Triage and Evaluation)
FOOTNOTES
a COVID-19 Suspect:
(1) A person who meets the clinical AND epidemiological criteria:
Clinical Criteria:
• Acute onset of fever AND cough; OR
• Acute onset of ANY THREE OR MORE of the following signs or symptoms: Fever, cough, general weakness/fatigue1, headache, myalgia, sore throat, coryza, dyspnoea,
anorexia/nausea/vomiting1, diarrhoea, altered mental status
Epidemiological Criteria
• Residing or working in an area with high risk of transmission of virus: closed residential settings, humanitarian settings such as camp and camp-like settings for displaced persons;
anytime within the 14 days prior to symptom onset; or
• Residing or travel to an area with community transmission anytime within the 14 days prior to symptom onset; or
• Working in any health care setting, including within health facilities or within the community; any time within the 14 days prior of symptom onset
(2) A patient with severe acute respiratory illness: (SARI: acute respiratory infection with history of fever or measured fever of ≥ 38 C°; and cough; with onset within the last 10 days; and
requires hospitalization)
(3) Asymptomatic person not meeting epidemiologic criteria with a positive SARS-CoV-2 Antigen-RDT
b Administer acute care for the patient while considering admission and service capability. Service capability as basis for admission can depend on multiple factors including:
(1) Best clinical judgement of the health provider
(2) Appropriateness of health care facility
(3) Geographical access to the next higher level facility
(4) Patient context
c
Close contact: A person who failed in two or more of the following exposures to a probable or confirmed case:
- Poorly ventilated indoor area
- Distance less than 1 meter
- Unprotected/no PPE
- Exposure >15 mins
d
A cluster is a group of symptomatic individuals linked by time, geographic location and common exposures, containing at least one RT-PCR confirmed case OR at least two epidemiologically
linked, symptomatic {meeting clinical criteria in footnote b) persons with positive Rapid Antigen Test.
e
Typical chest imaging findings of COVID-19:
- Chest radiography – hazy opacities, often rounded in morphology, with peripheral and lower lung distribution
- Chest CT – multiple bilateral ground glass opacities, often rounded in morphology, with peripheral and lower lung distribution;
- Lung ultrasound – thickened pleural lines, B lines, consolidative patterns with or without air bronchograms.
Figure E2 – Severe COVID-19 (Management)
1
From Figure E1 FOOTNOTES:

a
COVID-19 Suspect:
I. A person who meets the clinical AND epidemiological criteria:
Clinical Criteria:
2 • Acute onset of fever AND cough; OR
• Acute onset of ANY THREE OR MORE of the following signs or symptoms: Fever, cough, general
SEVERE weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnoea, anorexia/nausea/vomiting,
(Suspect, Probable or diarrhoea, altered mental status
Confirmed) COVID-19 Epidemiological Criteria
• Residing or working in an area with high risk of transmission of virus: closed residential settings,
humanitarian settings such as camp and camp-like settings for displaced persons; anytime within the
3 14 days prior to symptom onset; or
Refer to • Residing or travel to an area with community transmission anytime within the 14 days prior to
Pulmonologist and symptom onset; or
Infectious Disease • Working in any health care setting, including within health facilities or within the community; any time
within the 14 days prior of symptom onset
Specialist
II. A patient with severe acute respiratory illness: (SARI: acute respiratory infection with history of fever or
4 measured fever of ≥ 38 C°; and cough; with onset within the last 10 days; and requires hospitalization)
III. Asymptomatic person not meeting epidemiologic criteria with a positive SARS-CoV-2 Antigen-RDT
Confirm Advanced b
Directives Need informed consent BEFORE using COVID-19 investigational drugs & interventions in trials or compassionate
use
c
Investigational drugs for Severe COVID-19
5 - Remdesivir 200 mg IV loading dose then 100 mg IV OD, infused over 30 mins. For 5-10 days
- Immunomodulator (Tocilizumab)
Give LMWH as
d Improvement of clinical status
thromboprophylaxis
- No fever or use of antipyretic for at least 24 hours
- CXT (if available) shows significant improvement
6
Give Dexamethasone
6 mg IV x 10 days
Consider participation 7
in clinical trial OR
compassionate use
of investigational
drugsb,c
8 9 10 11
Patient is on Not recommended
Y Does patient Y Y to start Remdesivir
SpO2 < 94% invasive
require O2 (Remdesivir can be
at room air? mechanical
support? continued if initiated prior
ventilation? to invasive ventilation)
N N N
12
Consider addition of
Remdesivir
in treatment
13 14 15
Consider reclassifying
Deteriorating
Y See Navigation
as Critical (Suspect,
clinical status? Probable or Table
Confirmed) COVID-19
N 16 17
See Figure E3
Improvement of
Discharge of Severe
Clinical Statusd
COVID-19
Figure E3 – Severe COVID-19 (Discharge and Reintegration)
FOOTNOTES
1 aImprovement of clinical status

From • Respiratory symptoms reduced significantly
Figure E2 • CXR (if available) shows significant improvement
b
Immunocompromised individuals are patients:
2
• With untreated HIV infection with CD4 T-lymphocyte count <200
• With Combined immunodeficiency disorder
Improving • Taking prednisone 20 mg/day for more than 14 days
Severe COVID-19
c
regardless of severity.
3
d
Health management of discharged patients
Wait for 21 days • Close follow-up is still required
since onset of • His/her place of residence and address should be recorded and the local
symptoms government unit informed.
- Continue to wear mask, practice cough etiquette and maintain
4 physical distancing at home
Wait for clinical - If fever and/or respiratory symptoms recur, the primary health care
improvementa facility should assist in sending them to the designated medical
AND institutions in the area for assessment and treatment. This should be
no antipyretic use
for ≥ 24 hours reported to the surveillance units of the Department of Health.
eReferto workplace guidelines

5 1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)
Is the patient Y
Immuno-
compromisedb?
N
6 7 8 9
10
Is the
Repeat
patient a Y RT-PCR test Y Y Refer to Infectious
Do RT-PCR RT-PCR
healthcare available? Disease specialist
Positive?
worker?
N N N
11 12 13
May return to
Discharge from Recovered
worke. No further
isolationc,d Severe COVID-19
tests necessary
FIGURE F1-F3
CRITICAL COVID-19
24
1
Figure F1 – Critical COVID-19 (Triage and Evaluation)
CRITICAL
Suspect Return to Navigation
N
2 3 4
8
Cardiopulmonary
Patient not Y (CP) Arrest,
Is the patient in Y See Figure F2.1
breathing or COVID-19 Suspect
a hospital? for Advanced ACLS
without pulse? until proven
otherwise
N N 5
6
See Figure G2 See Figure G1

Stabilize patienta Emergency
Prepare for for Out of Hospital
and Transport
transport if needed Cardiac Arrest
Algorithms
7 8
COVID-19 RT-
See Figure J1 PCR test Y
for Advance Care
available and
Planning b
feasible? c
N
9 10
Rapid Antigen Do test;

Y Maintain isolation
test available
of symptomatic
and feasibled
patient
N
11
Positive RT- Y
PCR/Antigen
FOOTNOTES Test results?
a N
Administer acute care for the patient while considering admission and
12
service capability. Service capability as basis for admission can depend Close Contacte
on multiple factors including: (1) best clinical judgement of the health or linked to a Y
provider (2) appropriateness of health care facility (3) geographical
COVID-19
access to the next higher level facility (4) patient context.
cluster?f
b N 13
The advance directive should always be reviewed with the family.
With recent
c
RT-PCR anosmia or Y
- Should be performed by a nationally accredited laboratory ageusia in the
- Nasopharyngeal swab, saliva drool/spit samples can be used absence of other
identified cause?
dRapid Antigen Test N 14
- Only FDA and RITM-approved Rapid Antigen Test Kits may be procured 15 16 17
- Sample collected should be via nasopharyngeal swab IF chest imaging Repeat RT-PCR/
Y Antigen Test; Positive CRITICAL
- Should not be used in settings with an expected low prevalence of done, findingsg Y
RT-PCR/Antigen Confirmed
disease, and for populations with no known exposure suggestive of Maintain
test results?
COVID-19? isolation
e CloseContact: Two or more of the following exposures to a probable or N N
confirmed case in the past 14 days: poorly ventilated indoor area, 18 19 20
distance < 1 meter, unprotected/no PPE, exposure >15 mins Ensure that
Examples: living with or caring for a COVID-19 patient NON COVID CRITICAL contact tracing
Usual Care PROBABLE has been initiated
fThe thru CESU/MESU
cluster should have at least one confirmed case.
g
Typical chest imaging findings of COVID-19: 21
1. Chest radiography - hazy opacities, often rounded in morphology, See Figure F2
with peripheral and lower lung distribution; for Management of
2. Chest CT - multiple bilateral ground glass opacities, often rounded in CRITICAL
morphology, with peripheral and lower lung distribution;
3. Lung ultrasound - thickened pleural lines, B lines, consolidative
patterns with or without air bronchograms.
16
Figure F2 – Critical COVID-19 (Management)
1
FOOTNOTES
From Figure F1
a The advance directive should always be reviewed with the family.
See Figure J for Advance Care Planning
2 Guidelines on Advance Directives (DNR)

CRITICAL
1. Medical team may withhold CPR on critically ill patients with NO
Suspect/
reasonable chance of recovery (i.e., ARDS secondary to high-risk
Confirmed/
pneumonia and unresponsive to treatment, refractory septic shock,
Probable
multi-organ failure)
3 2. Free and informed decision for DNR made by competent patient

through an advanced directive should be followed
Confirm Advance
Directive as 3. Without advanced directive, the free and informed decision of proxy
Necessary a of an incompetent patient should be followed
4. Without patient’s or proxy’s decision, the medical team can decide

4 5 based on futility, the best interest of patient, and scarcity of resources
Patient not See Figure F2.1
Y 5.Efforts to provide spiritual care and counseling to the patient and
breathing or for Advanced Cardiac family must be done
without pulse? Life Support (ACLS)
N 6 7
Patient develops
See Figure F2.2
respiratory distress Y
for Management
AND unstable
of ARDS
vital signs?
N
8 9
Patient develops See Figure F2.3

Y
sepsis or for Sepsis
septic shock? Management
N 10 11
Irreversible Y See Figure H for

respiratory failure? End of Life Care
N
13 14
Y See Figure I for

Patient expired
Post Mortem Care
N 15 16
Refer to
Improvement
Figure F3
of clinical status
for discharge
Figure F2.1 – Critical COVID-19 (Advanced Cardiac Life Support or ACLS)
1 Return to Navigation
From Figure F2
FOOTNOTES
1 a The advance directive should always be reviewed with the family. See Figure J
for Advance Care Planning
COVID-19 Patient
Guidelines on Advance Directives (DNR)
in Arrest
1. Medical team may withhold CPR on critically ill patients with NO reasonable
chance of recovery (i.e., ARDS secondary to high-risk pneumonia and
unresponsive to treatment, refractory septic shock, multi-organ failure)
2 2. Free and informed decision for DNR made by competent patient through an
advanced directive should be followed
Advance Y 3. Without advanced directive, the free and informed decision of proxy of an
directive available a incompetent patient should be followed
4. Without patient’s or proxy’s decision, the medical team can decide based on
futility, the best interest of patient, and scarcity of resources
N 5.Efforts to provide spiritual care and counseling to the patient and family must
3 4
be done
Does the Y
Proxy decision Y b The medical team becomes decision maker in the absence of proxy
directive favor
maker is available b resuscitation? c Early
Intubation
Do early intubation with most experienced person with the use of video-guided
N N laryngoscope. Can start bag-mask ventilation with HEPA filter.
5 6
d Hands-only CPR
Consider
Y Do-Not- Chest compressions only. Consider use of mechanical compressor if available to
Recovery unlikely?
Resuscitate eliminate need for manual compressions. Cover patient's mouth and nose with
(DNR) cloth/barrier. Limit number of team to limit exposure. Continue CPR on the
following mechanical ventilator settings: mechanical ventilator at FiO2 100%,
N back-up rate 12/min. Avoid bag-mask ventilation (BMV).
Provide 7
postmortem care
and bereavement
support
8 9
Initiate CPR with On mechanical Y

proper PPE ventilator?
N
10 11 12
Do early Continue CPR on

Early intubation Y
possible? intubationc mechanical
with proper PPE ventilator a, d
N
13 14 15
Return of Continue
Do hands only Y
spontaneous supportive or
CPR d critical care
circulation?
N
16 17
Provide Reassess.
postmortem care See Figure F2
and bereavement Management of
support Critical of Patients
18
See Figure L for 27

Post Mortem Care
Figure F2.2 – Critical COVID-19 (Management of Acute Respiratory Distress Syndrome or CARDS)
FOOTNOTES
a dIntensive pulmonary care bundle

Oxygen support therapy
Oxygen support is delivered via face mask or 1. Airborne precautions should be followed
non-rebreather mask with hepa filter. • Bag-mask ventilation is not recommended, unless with hepa filter. Place
May use high flow nasal cannula at 40-60 patient on 6L oxygen support via nasal cannula for pre-oxygenation.
L/min overlapped with a face mask and non- • Avoid disconnecting patient from the ventilator
invasive positive pressure ventilation in a • Nebulization is not recommended. Use metered dose inhalers.
1 single negative pressure room. Maintain • Use in-line catheters for suctioning.
O2St >92% • Endotracheal intubation should be performed by a trained provider using the
From Figure F2 proper PPE. One-time intubation only using rapid sequence intubation is ideal.
b
ROX Index (SpO2/FiO2)/RR Use video laryngoscope if available.
Perform intubation if the ROX index are less 2. ICU admission
than these values at the hours of checking 3. Conservative fluid management
2 2 hours - < 2.8 4. Give empiric antimicrobials, guided by the guidelines on Community-Acquired
COVID-19 Patient 6 hours - < 3.47 Pneumonia, only if highly suspecting bacterial co-infection.
with respiratory 12 hours - < 3.85 5. Consider neuromuscular blockade in intubated patient with moderate-severe
distress and ARDS.
unstable vital c
Intubation 6. Give anticoagulation therapy.
signs Intubate with most experienced person with 7. Give dexamethasone 6 mg/day for 10 days
the use of video-guided laryngoscope. Can 8. Refer to pulmonologist or intensivist
start bag-mask ventilation with HEPA filter. 9. Initiate recruitment maneuvers and lung protection strategies
3
• Tidal volume 6-8mL/kg of predicted body weight
• Plateau pressure <30mmHg
Respiratory Y
• Use lower PEEP <10mmHg
rate >30 • Consider prone positioning for >12 hours in institutions with proper training
for maneuver
N • Consider extracorporeal life support
4 10. Consider investigational drugs for Critical COVID-19
Peripheral • Immunomodulator (Tocilizumab)
Y
capillary
oxygen saturation
<92%?
N
5 6 7
Start oxygen
Systolic support therapya
Y Computed Y
blood high flow nasal
pressure cannula at 40-60 ROX Index b
<90? lpm overlapped < 4.88
with face mask
N N
8
9 10 11 12
Consider Acute Refer to
Continue
Other indicators Y Respiratory Intubate c Pulmonary
supportive
for intubation? Distress with proper PPE Specialist for
management
Syndrome (ARDS) Intensive care
N
13 14
Intensive
Continue oxygen Pulmonary Care
support therapya Bundle d
15
Reassess.
See Figure F2
Management of
Critical of Patients
28
Figure F2.3 – Critical COVID-19 (Management of Sepsis)
See Figure F2
COVID-19 Patient
with suspected
sepsis
3 4
Y
qSOFA > 2? a Sepsis
N
5 6 7 8
Systemic Consider referral
Y Inflammatory Standard care for
SIRS> 2? b to intensive care
Response sepsis c specialist c
Syndrome
N
9 10
Reassess.
See Figure F2
Sepsis not likely
Management of
Critical of Patients
FOOTNOTES
aqSOFA Variables
-Respiratory rate >22 breaths/min
-Altered mentation
-Systolic blood pressure <100mmHg
bSystemic Inflammatory Response Syndrome (SIRS) Criteria

1.Temperature >38°C or <36 °C
2.Heart rate >90 beats/min
3.Respiratory rate >20 breaths/min, or paCO2 <32mmHg
4.WBC count >12,000 or <4,000 cells/mm³, or >20% immature (band) forms
cStandard of care for sepsis: (Intensive Care for Severe Sepsis and Septic Shock)
1. Admit patient to the ICU.
2. Give antimicrobials within 1 hour of initial patient assessment. Follow current Guidelines for Diagnosis and Treatment of CAP in Adults.
3. Blood cultures ideally should be collected prior to antimicrobial treatment, but should not delay administration of antimicrobials.
4. Early effective fluid resuscitation needed
• Administer at least 30 mL/kg of isotonic crystalloid in adults in the first 3 hours.
• Monitor for volume overload during resuscitation.
5. Apply vasopressors when shock persists in the for of norepinephrine, vasopressin, or dobutamine (if with signs of poor perfusion and cardiac dysfunction.
6. Maintain initial BP target as MAP > or = to 65 mmHg.
7. Insert central venous catheters. If not available, vasopressors may be given through peripheral IV access with the use of a large vein. 29
Figure F3 – Critical COVID-19 (Discharge and Reintegration)
1
FOOTNOTES
See Figure F2 a
Improvement of clinical status
• Respiratory symptoms reduced significantly
2
Improving bImmunocompromised individuals are patients
CRITICAL • On chemotherapy for cancer
Suspect/ • Untreated HIV infection with CD4 T-lymphocyte count <200
Probable/ • Combined immunodeficiency disorder
Confirmed • Taking prednisone 20 mg/day for more than 14 days
3 c
Wait for 21 days regardless of severity.
since onset of dHealth management of discharged patients
symptoms
4
Wait for clinical • Continue to wear mask, practice cough etiquette and maintain physical
improvementa
AND distancing at home
no antipyretic use • If fever and/or respiratory symptoms recur, the primary health care
for ≥ 24 hours facility should assist in sending them to the designated medical
5 reported to the surveillance units of the Department of Health.
e
Is the patient Refer to workplace guidelines
Y
Immuno- 1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)
compromisedb? 2. DOH Workplace Handbook as of September 30, 2020
N
6
7 8 9
Is the
patient a Y Repeat
RT-PCR test Y Y Refer to Infectious
healthcare RT-PCR
worker? Positive?
N N N
11 10 12
11

Discharge from Y CRITICAL worke. No further
isolationc,d Case tests necessary
FIGURE G1-G5
EMERGENCY DEPARTMENT
AND TRANSPORT
31
FIGURE G1. Management of Out of Hospital Cardiac Arrest
(OHCA) During Pandemics
1
CHECK.
Check own safety
prior to attending See Figure I1 PPE FOOTNOTES
to patient. Wear
PPE.
5C's of Out-of-Hospital Cardiac Arrest (Check, Call, Cover, Compress, Connect).
2
CHECK. aCHECK for personal safety, safety of the environment and patient's status.
Patient is Abnormal Breathing- No breathing or agonal, gasping without pulse.
unconscious with
no normal bCALL EMS for Telephone-Assisted CPR and follow instructions
breathinga. cCOVER the patient's mouth with mask if available or cloth and cover yourself with a
3 mask
d
CALL. Tell the caller:
Call EMS for 1. Bring the phone and get next to the person if you can.
Telephone- 2. Listen carefully. I’ll tell you what to do.
Assisted CPRb A. Place the victim flat on his back on the floor.
B. Kneel by the victim’s side.
C. Put the heel of your hand on the center of the victim’s chest.
4 D. Put your other hand on top of that hand.
COVER. E. With your arms straight, COMPRESS as hard as you can with the heels of your hands.
Instruct the caller or any
family member to wear
Do it 10 times and count with me: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 (The rate should be corrected
mask and coverc as needed. The ideal rate is at least 100 compressions per minute. If necessary, the caller
patient’s mouth and should be told to come back to the phone.) Keep going, push hard and fast and count out
nose with mask or cloth loud to10 over and over again. II will stay on the phone. Keep doing it until
help/dispatched ambulance arrives.
5 eCONNECT AED and follow voice prompt
f
COMPRESS. Follow institutional protocol or local EMS Protocol
Start Hans-only
CPR until EMS help
arrivesd
6 7 8
CONNECT.
Automated
EMS arrives Y Attach AED and
Defibrillator
on scene follow voice
present?
prompte.
N 9 10 11
Is Direct Is Return of
Continue CPR. Y Y
Medical Spontaneous
Prepare for rapid
Oversight Circulation
transport achieved?
availablef?
N N
12
See Figure L for

Post Mortem Care
13 14
Coordinate with
institutional or Call for Medical
LGU Command Direction
Center
See Figure G4 . 15
Management
of COVID
Patient in transit
Figure G2 – Pre-Hospital (Primary) Transport*
1
Patient for
transport to
healthcare
facility
2 3 4
Is direct
Is patient Y medical Y Call for Medical
unstable on
oversight Direction
scene?
available?
N N
5 6
Coordinate with
institutional or Coordinatea with a
LGU Command receiving facilityb
Center
7
Transport patient
in a COVID ready
FOOTNOTES ambulance with
IPCc measures
aConfirm that receiving facility is ready for patient's arrival and patient's
transfer location. Communicate patient updates and management
steps taken to facilitate event-free transport. Provide estimated time of
arrival (ETA) for ambulance at sending facility. See Figure G4 .
Management
of COVID
bReceiving health facility equipped with appropriate resources, Patient in transit
specialties, capacity and availability to receive and treat patient.
cSatisfy following criteria: (1.) Isolate the ambulance driver from the
patient compartment and keep pass-through doors and windows tightly
shut; (2.) Use vehicles that have isolated driver and patient
compartments that can provide separate ventilation to each area.(3.) If
1 and 2 are not met, all windows are kept open to ensure adequate
airflow.
*Primary transportation: Transfer of a patient from the site of an

emergency (e.g., public place, residence or workplace) to a healthcare
facility.
Figure G3 – Inter-Facility (Secondary) Transport*
1
Patient for
transport to
appropriate
facility
2
Is patient
condition Y
safe for
transporta?
N
3 4 5 6
Continue Coordinate with
management at Communicatec
institutional or Arrangee patient
current facility until with receiving
patient stabilizes LGU Command transport
facilityd
(See Fig C2 and D2) Centerb
7
FOOTNOTES Transport patient
to a COVID-ready
aReassess patient if safe for transport. Transport only clinically stable patient with stable vital signs. This ambulance with
also includes transport of stable high risk patients who require advanced airway but secured (intubated, IPC measuresf
on ventilator) and patients on vasoactive medication drips.
8
bCoordinate with One Hospital Command Center in Metro Manila. Healthcare worker
team endorse
patient to
cConfirm that receiving facility is ready for patient's arrival and patient's transfer location. Communicate transporting team
patient updates and management steps taken to facilitate event-free transport. Provide estimated time
of arrival (ETA) for ambulance at sending facility. 9
dReceiving health facility equipped with appropriate resources, specialties, capacity and availability to Transporting team
receive and treat patient. receives patient
e
Ensure that destination facility can be reached timely and safely. Communicate directly with an
accepting provider and check that patient's needs match the available services in the destination
facilities: See Figure G4 .
(a.) Admit Moderate (>60 years old) to Severe Suspect, Probable or Confirmed COVID-19 to Level 3 Management
COVID Hospital. Admit Moderate (<60 years old with stable co-morbid) Suspect, Probable or Confirmed of COVID
COVID-19 to Level 2 Hospital; Patient in transit
(b.) Isolate Asymptomatic to Mild Suspect, Probable or Confirmed COVID-19 to LIGTAS or TTMF;
(c.) Step up care referral from LIGTAS/TTMF to Level 3 COVID Hospital;
(d.) Step down care referral from Level 3 COVID Hospital to LIGTAS/TTMF
fSatisfyfollowing criteria: (1.) Isolate the ambulance driver from the patient compartment and keep pass-
through doors and windows tightly shut; (2.) Use vehicles that have isolated driver and patient
compartments that can provide separate ventilation to each area. (3.) If 1 and 2 are not met, all windows
are kept open to ensure adequate airflow.
Inter-facility transfer also known as secondary transport- any transfer, after initial assessment and
stabilization, from and to a health care facility (Level 1, 2 or 3 non-COVID hospitals to COVID-19
hospitals, TTMF and LIGTAS).
Figure G4 – Management for Suspect, Probable, or Confirmeda
1
COVID-19 Patient in Transit
Patient for
transport to
appropriate
facility
2
FOOTNOTES
Check own safety
a
See Figure I1 for All patients transported by an appropriate transport vehicle (ALS or BLS that is either institution or
proper PPE LGU-based) accompanied by a team of healthcare workers from residence or any referring point
of care to a designated facility and vice versa.
3 bFor Stable patients, re-assess every 15 minutes, if not, every 5 minutes. If no pulse and no
breathing, follow BLS Protocol and medical oversight.
Re-assess with c
If conversant, airway is patent. If altered mentation, may not be able to protect the airway and
ABCDE approachb
may be at risk for choking or obstructing airway.
d
Provide mask; If choking, do Heimlich maneuver; Open airway through head-tilt-chin-lift maneuver
4 (non-trauma) or jaw thrust (trauma). Suction secretions with viral filter. Put oropharyngeal airway if
without gag reflex. Give oxygenation if warranted; if intubated, connect to a viral filter.
Is the
Y
AIRWAY eLook for signs of difficulty in breathing or cyanosis. Check for breath sounds
patentc?
f
Look for and manage signs of shock: Low blood pressure, Elevated heart rate,
N 5 6 Delayed capillary refill (CRT>2sec); Is there an active external bleeding?
Coordinate with Is the gRemove wet clothing, and warm the patient. Start IV line if not yet inserted. Provide IV crystalloid
institutional or patient Y
at 10cc/kg then reassess, or start intravenous hydration with direct medical oversight. If you cannot
LGU Command BREATHING start an IV line, consider Nasogastric tube or Intraosseous line. Stop external bleeding with direct
Centerd normally?e pressure.
N
7 hGCS 15 or Awake on AVPU scale
i
Provide breathing Check glucose, Check pupils , Check strength and sensation; Hypoglycemia (CBG of < 70 mg/dl
adjuncts or <3.9 mmol/L with altered mental status: Call for Direct Medical Oversight (EMS) Treat with
Glucose. Give 1-2 amps of d50water then recheck for improvement of sensorium and Glucose
level. Hyperglycemia: Call for Direct Medical Oversight (EMS) If entertaining Diabetic
8 Ketoacidosis, treat with IV fluid hydration. Start at 2 liters of Crystalloid solution for adults and
Is the airway 20cc/kg hydration for pediatrics. If extremely ill, transfer with no delay to a facility with intensive
and Y care facility. Fever with Altered Sensorium: Call for Direct Medical Oversight (EMS) Start
breathing antibiotics and treat Fever with Paracetamol, if available. For severe hyperthermia, spray with cool
status water mist, fan and give IV fluids.
improved?
N 9
Does the
See Algorithm F2.2 patient has Y
adequate
for ARDS
CIRCULATION
and perfusionf?
N
10 11
Provide Does the
appropriate patient have
intact
circulation and DISABILITY and
perfusion mental health
managementg status?h
N
12 13 14 15
Provide Assessment of
Perform Secondary Handover to
appropriate EXPOSURE and
Survey and appropriate
Disability thermoregulate
SAMPLE history receiving facility
Management properly
Return to navigation
table for further
Management.
Figure G5 – Infection Prevention and Control for Ambulance EMS Team
1
HCW to
accompany
patient for
transport
2 3 4 5 6
Does the Keep pass-through Does the EMS team
vehicle have a doors and windows passenger
Y Y member with Y
separate tightly shut and compartment NO direct
Stay in the Driver’s
patient provide separate have IPC Compartment
patient
compartment ventilation to each measure? contact?
? area
N N N
7 8 9
Keep all windows

open to ensure Wear appropriate
Level 3a PPE
adequate airflow? PPE
10
Follow proper
See Figure I1 PPE donning, doffing,
cleaning and
disposal of PPE
11
FOOTNOTES
Observe frequent
aFit Tested N95 or any equivalent filtering face-piece respirator, water and proper hand-
impermeable gown, double gloves, dedicated shoes, shoe covers and hygiene
goggles or face shield
FIGURE H1-H3
PREGNANCY, LABOR AND
NEWBORN CARE
37
Figure H1 – Management of Pregnant Women During the COVID-19 Pandemic
1
Pregnant
Woman
2
Counsel and
implement Infection
Prevention and
a
Control measures
on all patients
3 4 5 6
W/ COVID-19 W/ ANY of the Moderate / Stabilize and coordinate
7
signs and following: Figure G2
b 1. danger signsf; Severe / Critical transfer to higher-level
Primary Transport
symptoms OR Y 2. ANY comorbidsg; 3. Y COVID-19 COVID-19 facility for
exposed by OR
c
travel ,
severe COVID managementJ OR
symptomsh; 4. other Suspect, Figure G3
residenced, or medical / obstetric COVID-19 CEmONCk
SecondaryTransport
contacte? indicationi? Pregnant Patient facility
N N
8 9 10
11
Mild COVID-19
Non-COVID-19 Is the woman Y See Figure H2
Suspect Intrapartum
Pregnant Patient in labor? Management
Pregnant Patient
N
12 13 14 15
With danger Stabilize and Advise on modified
See Figure C2
signf or other coordinate antenatal care and
Y Management of
medical / transfer to birth planning in the
i Mild Cases
obstetric
CEmONC facility context of COVID-19
indication?
N
16 17
Modified Figure G2
antenatal care and Primary Transport
birth planning in OR
Figure G3
the context of SecondaryTransport
COVID-19 l
FOOTNOTES
hSevere COVID symptoms:
- Altered mental state
aMaternal Infection Prevention and Control (IPC) -Shortness of breath
Prior to the use of this algorithm, it is expected that the mother is already aware of and following maternal IPC measures: -SpO2<94%
- A minimum of a face mask must be worn by or provided to the mother during delivery, postpartum, and during care of the baby
-Respiratory rate > 30/min
- Wash hands using soap and water immediately before and immediately after handling infants
- On nipple care, as long as IPC measures above are observed washing/cleaning the nipple before/after feeding is discouraged -Systolic blood pressure of <90mmHg
-Other signs of shock or complications
bCommon signs and symptoms of COVID-19
fever, cough, general weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia, nausea, vomiting, diarrhea, i Examples of High-risk features
altered mental status, anosmia, ageusia/dysgeusia
-Preterm labor
cExposure by travel -Vaginal bleeding
Travel from a country/area where there is sustained community level transmission -Pre-eclampsia/eclampsia
-Preterm pre-labor rupture of membranes (pPROM)
dExposure by residence -Malpresentations
Lives in an LGU where there is sustained community level transmission
-Young primigravid
eExposure by contact -Elderly primigravid
1. Providing direct care to suspect, probable, or confirmed COVID-19 patients without using proper PPE (i.e. healthcare workers); -Multifetal pregnancy
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 J
Transporting a Patient
4. Other situations as indicated by local risk assessments
- Stabilize patient prior to transport: Give oxygen; Target pulse oximetry 92-95% at room air
fObstetric danger signs (DOH MNCHN MOP, 2011) - Require all transport personnel to wear appropriate PPE, to be removed once patient has been transferred
1. Swelling of legs, hands, and/or face ~ Stabilize patient using corresponding interventions as per BEmONC guidelines
2. Severe headache, dizziness, blurring of vision
3. Convulsion k
CEmONC
4. Vaginal bleeding, pale skin
- Comprehensive Emergency Obstetricsand Newborn Care
5. Fever and chills
6. Absence or decrease in baby’s movement inside the womb,
iAntenatal Care
7. Severe abdominal pain
8. Vaginal bleeding, foul smelling/watery vaginal discharge -Consider modifications to standard protocols for antenatal visits and procedures, depending on levels of
9. Painful urination community quarantine including use of telehealth, reducing the number of clinic visits. (DOH DM 2020-0319)
10. Too weak to get out of bed
- Phone consultations recommended to minimize exposure risk
gComorbids - Underlying health condition listed below:-Chronic lung disease - Antenatal care under the current situation remains the same as standard of care, provided that physical
-Chronic heart disease or Hypertension distancing and IPC measures are still followed for in-person meetings
-Chronic kidney disease
- Emphasis on obstetric danger signs must be made during all consults, including the need to escalate care from
-Chronic liver disease
-Chronic neurological conditions remote healthcare to the need to transfer to health care facilities
-Diabetes - Antenatal discussions should include consideration of COVID-19 vaccination, feeding options, formulation of
-Problems with the spleen updated birth preparedness, and complication readiness plans that include when, where and how to seek
-Weakened immune system such as HIV or AIDS, or medicines such as steroid tablets or chemotherapy appropriate care
-Morbid obesity (BMI > 40)
Figure H2 - Management of COVID-19 Suspects or Cases in Labor
1 FOOTNOTES
H1
Management aMaternal Infection Prevention and Control (IPC)
of Pregnant Prior to the use of this algorithm, it is expected that the mother is
Women already aware of and following maternal IPC measures:
-A minimum of a face mask must be worn by or provided to the
mother during delivery, postpartum, and during care of the baby
2 -Wash hands using soap and water before and after handling baby
Counsel and -On nipple care, as long as IPC measures above are observed
implement Infection washing/cleaning the nipple before/after feeding is discouraged
Prevention and
a bIsolation Capacity
Control measures
on all patients Discuss the available options for isolating the mother-newborn dyads,
whether together or separated, with the mother/father. Are enough
isolation rooms available? Is there a dedicated unit for separated
3 newborns where they can be maintained >1m apart?
Is the Isolation in Imminent Delivery
Y -Admit to a designated isolation area
patient in
-Require all personnel in attendance to wear the appropriate PPE
active
-Require all transport personnel to wear the appropriate PPE to be
labor? removed once patient has been transferred
-Delivered by NSD
N -Obtain/verify if the naso-oropharyngeal swab specimens were
4 5
Discuss: collected
Does the facility 1.Feasibility of alternate
have
caregivingc and feedingd
Infection
Prevention and
Y options for the next 2
cAlternative Caregivers
Controla measures weeks, -Should mother prefer separation, alternate caregivers include all
2. Benefits/risks of non possible contacts (e.g. health workers, family members) of the baby
& isolation
separation(skin to skin
capacityb ? during the time of separation from the mother
contact)e
N -Discuss with the family who the available alternate caregiver(s) will
7 8 be, what their COVID status are, what the transmission risks are, how
6 Mother much PPEs are needed, and how available are these PPEs
See Figure G2 Deliver the baby -Alternate caregivers must also undergo assessment regarding
prefers Y
Interfacility non- following Unang symptoms, contact, and exposure via residence or travel
Referral separationd Yakap Stepsf dHierarchy of feeding options
of newborn? 1. Direct breastfeeding with IPC
N 2. Expressed breastmilk with IPC
9 10 3. Donor breastmilk, preferably pasteurized
Deliver the baby, 4. Hygienically and properly prepared breastmilk substitutes, only after
dry immediately, all above have been exhausted
clamp and cut the Live birth eNon-Separation
cord at 1-3 -Non-separation keeps babies warm, prevents exposure to microbes in
minutes the immediate environment, and helps establish breastfeeding.
Delaying the first breastfeed outside of the first 60-90 minutes
11 increases risk for infection-related deaths among newborns and results
in breastfeeding difficulties. Breastfeeding problems can undermine
food security of a household with limited resources, as funds are
Postpartum Careg funneled to prioritize infant formula. New evidence has demonstrated
that COVID-19 antibodies are found in the breastmilk of infected
mothers.
fNeonatal Care
Unang Yakap Steps
12 -Immediate and thorough drying, early skin-to-skin contact, cord
See Figure H3 clamping/cutting between 1-3 mins after delivery, non-separation until
on Newborn first breastfeed is completed
Care -Institute appropriate neonatal resuscitation measures as necessary
gPostpartum Care
-Monitor postpartum patient in the same isolation area by the same
delivery team
-For HESU/MESU/CESU to coordinate with LGU for contact tracing
-Facilitate RT-PCR Testing (See Figure 1C, 2E)
-Discharge once stable, if mild case coordinate with HESU/MESU/CESU
to coordinate with LGU for community based isolation and monitoring
-If the mother agrees to non-separation, the mother and the baby
should always stay together
39
Figure H3 – Care of the Newborn whose Mother is a
Probable/Confirmed COVID-19 Case with Mild or No Symptoms
1
Figure H2
Intrapartum
Management
Live birtha
3 4 5
Discuss: Mother
1.Feasibility of alternate Y
Stable Y caregivingb and feedingc prefers non-
newborn? options for the next 2 weeks,
2. Benefits/risks of non separation
separation(skin to skin contact)d of newborn?
N N
6 7 8 10
9 11
Is the Is isolation of Mother
newborn in a the newborn prefers non- Uninterrupted
Y Continue NICU Y Rediscuss Y
facility with from the separation skin-to-skin
appropriate care Scenarios after
mother
e contactf
level of care? difficult ? rediscussion?
N N N
13 14
12 Advise alternate
See Figure G2 caregiver b
Interfacility on IPC g,h Counsel on EBFi
Referral Offer feeding optionsc with IPC g,h
Implement separationd
15
FOOTNOTES After first full feed
aWHO Interim Guidance on the Clinical management of severe acute respiratory
is completed,
infection (SARI) when COVID-19 disease is suspected or confirmed (Jan 25, fDo NOT put mask on the newborn
proceed with
2021), recommends to:
routine care.i
Mothers should not be separated from their infants unless the mother is too sick gMaternal Infection Prevention and Control (IPC)
to care for her baby. If the mother is unable to care for the infant another Prior to the use of this algorithm, it is expected that the mother is already aware
competent family caregiver should be identified. Mother and infant should be of and following maternal IPC measures:
enabled to remain together while rooming-in throughout the day and night and -A minimum of a face mask must be worn by or provided to the mother during
16
practice skin-to-skin contact, including kangaroo mother care, especially delivery, postpartum, and during care of the baby Back to
immediately after birth and during establishment of breastfeeding, whether they -Wash hands using soap and water before and after handling baby Navigation
or their infants have suspected or confirmed COVID-19 virus infection. -On nipple care, as long as IPC measures above are observed washing/cleaning Table to
the nipple before/after feeding is discouraged
bAlternative Caregivers Classify Infant
-In the context of newborn care and breastfeeding, cough etiquette should be
-Should mother prefer separation, alternate caregivers include all possible into a tissue that is disposed immediately in proper bins, followed by hand
contacts (e.g. health workers, family members) of the baby during the time of hygiene practice
separation from the mother
-Discuss with the family who the available alternate caregiver(s) will be, what hCounseling on Exclusive Breastfeeding (EBF) with IPC
their COVID status are, what the transmission risks are, how much PPEs are 1. Exclusive breastfeeding per demand
needed, and how available are these PPEs 2. Positioning and attachment
-Alternate caregivers must also undergo assessment regarding symptoms, 3. Coughing/sneezing into tissue (not into elbow) and disposing
contact, and exposure via residence or travel 4. Proper way of wearing a mask when near her baby
5. Washing hands before and after contact with the baby
cHierarchy of feeding options 6. Cleaning/disinfecting contaminated surfaces, e.g. cellphone
1. Direct breastfeeding with IPC 7. Mother should be able to see the baby in an infant crib that is at least one (1)
2. Expressed breastmilk with IPC meter or three (3) feet away from mother's bed, exercising fall precautions.
3. Donor breastmilk, preferably pasteurized 8. EBF should not be stopped either before or after receiving any of the COVID-19
4. Hygienically and properly prepared breastmilk substitutes, only after all above vaccines.
options have been exhausted
iRoutine Care
dNon-Separation
-Eye care, thorough physical exam, vitamin K injection, birth doses of hepatitis B
-Non-separation keeps babies warm, prevents exposure to diseases in the and BCG vaccines; newborn and hearing screens, if available.
immediate environment, and helps establish breastfeeding. Delays in -Counsel mother and partner on family planning
breastfeeding increases risk for infection-related deaths among newborns, and
result in breastfeeding difficulties. Breastfeeding problems can undermine food jTesting
security of a household with limited resources, as funds are funneled to prioritize -RT-PCR testing may be done at DOH accredited testing centers at 24 hours or
infant formula. New evidence has demonstrated that COVID-19 antibodies are once newborn is stable
found in the breastmilk of infected mothers.
kIfthe mother agrees to non-separation, the mother and the baby should always
eIsolation feasibility stay together even when in quarantine or isolation
Discuss the available options for isolating the mother-newborn dyads, whether
together or separated, with the mother/father. Are enough isolation rooms
available? Is there a dedicated unit for separated newborns where they can be
maintained >1m apart? Upon discharge is isolation of the mother-newborn dyad
feasible at home?
FIGURE I1-I5
USE OF PERSONAL PROTECTIVE
EQUIPMENT
41
Figure I1 - Recommended PPE For Healthcare Workers
Healthcare
worker
Hospital Facility
Y
or EMS? See Figure I2
N
3
Outpatient Y
See Figure I3
Facility?
N
4
Works in the Y
Community? See Figure I4
N
5
BHERTs and
Contact Tracers See Figure I5
Figure I2 - Recommended PPE For Healthcare Workers In
Hospital Facilities And Emergency Medical Services
1
HCW in a
Hospital Facility
or EMS
FOOTNOTES
2 a
Aerosol generating procedures (not limited to the following):
≥4 hours stay in Airway surgeries (e.g. ENT< thoracic, transsphenoidal
a COVID-19 surgeries), autopsies, bronchoscopy (unless carried out
area or close Y
contact with
through a closed-circuit ventilation system,
confirmed/prob cardiopulmonary resuscitation, dental procedures,
able patient? endotracheal intubation and extubation, evacuation of
N pneumoperitoneum during laparoscopic procedures,
3 gastrointestinal endoscopy, high frequency oscillatory
ventilation, non-invasive ventilation (e.g. BiPAP, CPAP,
Performing high-flow nasal oxygen), open suctioning of airways,
aerosol- Y manual ventilation, nebulization, sputum induction, surgical
generating procedures using high-speed/high-energy devices (e.g.
procdeuresa?
high-speed cutters and drills, powered instrumentation,
suction microdebrider, tracheotomy/tracheostomy
N
4
b
Emergency High Risk for Transmission include any of the following:
procedure to be - aerosol generating procedures
done with Y - emergent/urgent/unplanned intervention needed or
patients with
unknown anticipated with unknown or unavailable result of RT-PCR
COVID-19 - handling of specimens of suspected or confirmed COVID-19
status? patients
N - confirmed COVID-19 patient
5 6 7
c
Low Risk for Transmission
Handling of Y - Negative RT-PCR result
respiratory Very High Riskb Level 4 PPEd,e - Asymptomatic patients with no respiratory symptoms or
specimens? concerns but pending RT-PCR results
d
Levels of PPE:
N - Level 4 PPE: Fit-tested N95 or any equivalent filtering
8
facepiece respirator, coveralls, double gloves, dedicated
shoe, shoe covers, and goggles or face shield
At Emergency Y - Level 3 PPE: Fit-tested N95 or any equivalent filtering
Department
facepiece respirator, water impermeable gown, double
Triage?
gloves, dedicated shoe, shoe covers, and goggles or face
shield
N
- Level 2 PPE: Fit-tested N95 or any equivalent filtering
9 10 11
facepiece respirator, goggles or face shield, with or without
<4 hours stay in a gown
COVID-19 area OR
brief patient Y - Level 1 PPE: Surgical mask
interaction with High Riskb Level 3 PPEd,e
e
confirmed/ Respirators with exhalation valves should not be used in
probable COVID-
19 patient? situations requiring a sterile area. May cover exhalation valve
N with a face mask taking precautions to maintain respirator fit if
12 13 14 resources are limited or with no alternatives
Caring for Y
non-COVID-19 Moderate Riskb Level 2 PPEd,e
patients?
N
15 16 17 18
Follow proper
No patient c d,e donning, doffing,
Low Risk Level 1 PPE
contact cleaning, and
disposal of PPE
19
Observe frequent
and proper hand
hygiene
Figure I3 - Recommended PPE For Healthcare Workers
In Outpatient Facilities in Areas with Sustained
Community Transmission
1
HCW in an Return to Navigation

Outpatient
Facility
2
FOOTNOTES
aLevels of PPE:
Patient Triage
Area
facepiece respirator, coveralls, double gloves, dedicated
shoe, shoe covers, and goggles or face shield
3 4 5 facepiece respirator, water impermeable gown, double
gloves, dedicated shoe, shoe covers, and goggles or face
Telehealth shield
Phone call Y consult
No PPE required - Level 2 PPE: Fit-tested N95 or any equivalent filtering
possible? Phone triage facepiece respirator, goggles or face shield, with or without
No Risk gown
- Level 1 PPE: Surgical mask
N
6 7
b
Observe frequent and proper hand hygiene. Follow proper
donning, doffing, cleaning, and disposal of PPE.
Outdoor Y
triage area Do outdoor triage c
Aerosol generating procedures (not limited to the following):
possible Airway surgeries (e.g. ENT< thoracic, transsphenoidal
surgeries), autopsies, bronchoscopy (unless carried out
N through a closed-circuit ventilation system,
8 9
cardiopulmonary resuscitation, dental procedures,
Triage area endotracheal intubation and extubation, evacuation of
with glass Y pneumoperitoneum during laparoscopic procedures,
Indoor triage with
barriers gastrointestinal endoscopy, high frequency oscillatory
barriers
possible? ventilation, non-invasive ventilation (e.g. BiPAP, CPAP,
high-flow nasal oxygen), open suctioning of airways,
N manual ventilation, nebulization, sputum induction, surgical
10 11 12 procedures using high-speed/high-energy devices (e.g.
high-speed cutters and drills, powered instrumentation,
No physical suction microdebrider, tracheotomy/tracheostomy
Triaged indoors
contact. Maintain Low Riskb
with no barrier
distance
13 14
Patient at
Level 1 PPEa,b consultation
room
15 16
Need to do
With direct aerosol
patient Y Y
generating
physical procedures?
contact? Exposure to
bodily fluids?
N N
17 18 19
Moderate Risk High Risk Very High Risk
20 21 22
Level 2 PPEa,b Level 3 PPEa,b Level 4 PPEa,b

Figure I4 - Recommended PPE For
Healthcare Workers In The Community
HCW in the
community
2
Direct care
for patient in Y
Community
Isolation
Unit?
N
3
Transporting
confirmed/ Y
suspect
COVID-19
patient?
N
4 5 6
Doing aerosol
generating
procedures or Y
with exposure
Very High Risk Level 4b,c
to bodlily
fluidsa?
N
7 8 9
Close patient
contact Y
Moderate Risk Level 2b,c
necessary or
unavoidable?
N
10 11
Low Risk Level 1b,c
FOOTNOTES
aAerosolgenerating procedures (not limited to the following): Airway surgeries (e.g. ENT< thoracic, transsphenoidal surgeries),
autopsies, bronchoscopy (unless carried out through a closed-circuit ventilation system, cardiopulmonary resuscitation, dental
procedures, endotracheal intubation and extubation, evacuation of pneumoperitoneum during laparoscopic procedures,
gastrointestinal endoscopy, high frequency oscillatory ventilation, non-invasive ventilation (e.g. BiPAP, CPAP, high-flow nasal
oxygen), open suctioning of airways, manual ventilation, nebulization, sputum induction, surgical procedures using high-speed/high-
energy devices (e.g. high-speed cutters and drills, powered instrumentation, suction microdebrider, tracheotomy/tracheostomy
b
Levels of PPE:
- Level 4 PPE: Fit-tested N95 or any equivalent filtering facepiece respirator, coveralls, double gloves, dedicated shoe, shoe covers, and
goggles or face shield
- Level 3 PPE: Fit-tested N95 or any equivalent filtering facepiece respirator, water impermeable gown, double gloves, dedicated shoe, shoe
covers, and goggles or face shield
- Level 2 PPE: Fit-tested N95 or any equivalent filtering facepiece respirator, goggles or face shield, with or without gown
- Level 1 PPE: Surgical mask
c
Observe frequent and proper hand hygiene. Follow proper donning, doffing, cleaning, and disposal of PPE.
Figure I5 – PPE for BHERTS and Contact Tracers
Assisting in Public Health Investigations
BHERTS/Contact
Tracersa
2 3
Offer remote
Remote interview Y review by phone
possible? or video. No PPE
required.
N
4
Do face-to-face
interview
5 6 7 8
Interviewing
Require outdoor
confirmed Y interview for
or suspect High Risk Level 3 PPEb,c
confirmed or
COVID-19
suspect cases
patient?
N
9 10 11
Offer outdoor
interview for Moderate Risk Level 2 PPEb,c
contacts
12
Outdoor Y
interview
possible?
FOOTNOTES N 14
13
aWHO interim guidance on rational use of personal protective equipment for COVID-19, Open doors or
windows. Refrain Observe minimum
February 27, 2020, refers to this group as “rapid response Team assisting in public health from touching public safety
investigations.” anything. Check
temperature. Limit
standards
bLevels of PPE interaction <15 min.
- Level 3 PPE: Fit-tested N95 or any equivalent filtering facepiece respirator, water
impermeable gown, double gloves, dedicated shoe, shoe covers, and goggles or face shield
- Level 2 PPE: Fit-tested N95 or any equivalent filtering facepiece respirator, goggles or face
shield, with or without gown
cObserve frequent and proper hand hygiene. Follow proper donning, doffing, cleaning, and
disposal of PPE.
FIGURE J
ADVANCED CARE PLANNING
47
Figure J – Advance Care Planning
FOOTNOTES
1 a
Timing of ACP Discussion
COVID-19 In a pandemic situation, advanced care planning at the onset of serious acute illness will be beneficial
Suspect/ and should be given priority. Proper timing of ACP discussion is important, should be sensitive and will
Probable/ depend on several factors including patient's clinical status and prognosis, patient/family preferences and
Confirmed values, and HCW team/facility capabilities among others. Too early discussion may cause distress and
demoralization, while too late may delay patient/family preparation for acute medical crisis, and cause
incongruences in patient care.
2
bAdvance Care Planning
Decision to
discuss Advance Advanced Care Planning is making decisions about the healthcare a patient would want to receive if one
Care Planning a, b is facing a medical crisis. This may take time so do not force arriving at a decision abruptly.
Advanced Care planning includes :
1. Assessing the patient's / decision-maker’s mental capacity to make informed decisions. Look for
signs of losing the capacity to understand information, to retain information, to use and weigh
3
information, and to communicate information.
Is the patient 2. Giving the patient / decision-maker information on the types of life-sustaining treatments that are
Y
capable of available.
decision-making? 3. Helping the patient / decision-maker decide what types of treatment he/she would or would not want
should the patient be diagnosed with a life-limiting illness.
4. Encouraging the patient / decision-maker to share one's personal values with loved ones.
N
5. Completing Advance Directives to put into writing what types of treatment the patient / decision-
4 5 maker would or would not want – and who to speak to – should the patient be unable to speak for
Substitute Patient-Family- himself/herself.
Y
decision-maker Physician 6. To ensure that the document reflects the current wishes of the patient, initiate a review of the
available?c Communicationd advance planning decisions if there is a change in the patient’s perception of their quality of life; For
patients that lack capacity, critical care teams should enquire about the presence of any ACP or
advanced statements to better understand the beliefs of the individual; and in a pandemic situation,
N
advanced care planning at the onset of serious acute illness will be beneficial and should be
6 7
Begin Advance given priority.
Medical Team Care Planning with cSubstitute Decision-maker
becomes Shared Decision-
decision-makere Making Model Appointed according to the following hierarchy:
Discussionf
1. Power of Attorney
2. Spouse (living together in a married or common-law relationship)
8 3. Parent or child
Accomplish / 4. Siblings
document 5. Other relatives
advance
directives g d
Patient-Family-Physician Communication
The guide includes the following reminders:
9 1. Ensure Comfort
Review goals of
2. Assess Emotional Temperature
care if patient’s
3. Listen to Patient Concerns
condition 4. Reassure
changes 5. Assess Need for Information
6. Deliver Information with Empathy
7. Explore Emotions and Provide Support
e
Medical Team becomes decision-maker
In the premise there is no appointed/surrogate decision-maker, medical team makes a "best interest"
decision following consultation with family members and any written statements. This is an attempt to
make the same decision the patient would in these circumstances should they have had capacity.
f
Shared decision making model
Key component process of patient-centered health care in which clinicians, patients and their families
work together to make decisions and select tests, treatments and care plans based on clinical evidence
that balances risks and expected outcomes with patient preferences and values.
g
Advanced Directive definition
An advance directive consists of a person's oral and written instructions about his or her future medical
care, in the event he or she becomes unable to communicate, becomes incompetent to make health care
decisions or is in a persistent vegetative state.
FIGURE K
END-OF-LIFE CARE
49
Figure K– End-of-Life Care for COVID-19 Patients
1
CRITICAL COVID-
19 Confirmed
patienta
2 3
Dyspnea Y Consider starting
Respiratory Rate
opioidsb
> 30 cpm
N
4 5
Respiratory Distress Y Continue current

Relieved? c opioid protocol
N
6
Can start opioid

infusiond
7 8
Agitation and/or Y Consider
Hyperactive Haloperidol or
Delirium? Midazolam e
N
9 10
Agitation/ Continue current
Delirium Relieved? Y
dose (alternatives
Dose given <3 times in
24 hours in footnotes) e
N
11
Consider to start
continuous
palliative sedationf
12 13 14
Treat other Maximize all

Actively dyingh
symptomsg comfort measuresi
15
Patient Expired
16
Provide
postmortem care
and bereavement
supportj
Figure K– End-of-Life Care for COVID-19 Patients
FOOTNOTES
a Prerequisite before using this algorithm
Patient/ substitute decision-maker are not amenable to life-sustaining interventions and/or medical team see no reasonable chance of recovery. Discussed de-escalation of care. Ensure psychosocial support and
provide spiritual care (may call spiritual care provider/ Chaplain) to patient and the family. May refer patient to palliative care team if available.
b Opioid options for dyspnea
(1) Morphine Sulfate 2-4 mg IV/IM/SC every 30 minutes. Monitor every 15 mins.
(2) Morphine 5-10 mg tab every 4 hours PO/NGT
(3) Fentanyl IV continuous drip 12.5 mcg/hour
(4) Oxycodone IV 10-20 mg every 4-6 hours
(5) Oxycodone PO/NGT short-acting 10-20 mg every 4-6 hours
* Do opioid precaution monitoring for opioid-naïve patients

* Do dose adjustment for opioid-tolerant patients
c Respiratory Distress relieved
(1) Respiratory Rate <20 cpm
(2) Severity score using the Visual Analog Scale (VAS) <5 out of 10
d Opioid Infusion Principles

(1) If initial dose of IV opioid is ineffective after 2 doses at least 15 minutes apart, double the dose
(2) Typically need 6-8 hours of controlled symptoms to calculate a continuous opioid infusion
(3) If starting a continuous infusion, do not change more often than every 6 hours. Adjust infusion dose based on the 24 hour sum of PRNs
e Medications for Agitation/ Delirium

(1) Haloperidol 2.5 mg IM/SC every 4 hours PRN
(2) Midazolam 2 mg IV every 4 hours PRN
(3) Midazolam 7.5-15 mg PO every 4-6 hours PRN
(4) Diazepam 5 mg IV
(5) Rectal Diazepam 10 mg
(6) Diazepam 5 mg PO/NGT
f PalliativeSedation
Palliative sedation is a measure of last resort used at the end of life to relieve severe and refractory symptoms. It is performed by the administration of sedative medications in monitored settings and is aimed at
inducing a state of decreased awareness or absent awareness (unconsciousness). The intent of palliative sedation is to relieve the burden of otherwise intolerable suffering for terminally ill patients and to do so in
such a manner so as to preserve the moral sensibilities of the patient, the medical professionals involved in their care, and concerned family and friends.
Titrate sedatives accordingly every 2 hours to determine effectiveness of palliative sedation until the desired level of comfort is acceptable to the family and the medical team caring for the patient. (May use
palliative sedation scoring system i.e. RASS, Ramsay Sedation scale)
Midazolam Infusion
Start Midazolam drip 20 mg in 30 ml PNSS to run at 2 cc (2 mg)/hour, titrate by increments of 1 mg/mL every hour until agitation is adequately controlled and maintain at that dose
Alternative to Midazolam for palliative sedation: Rectal Diazepam 10 mg every hour or Clonazepam 1-2 mg sublingual q6 hourly.
g Other symptoms
(1) Anxiety:
• Diazepam 2 mg IV/IM/SC
• Diazepam 5 mg PO/NGT every 8 hours
• Midazolam 2 mg IV q4 or Midazolam 7.5-15 mg PO q4-6 hours
(2) Cough:
• Butamirate citrate 50 mg PO/NGT q8-12 hours
• Levodropropizine 30 mg PO/NGT q8 hourly
• Morphine 2.5 mg IV/SC PRN
• Morphine Controlled Release 10-20 mg q12 hours
• Oxycodone 5-10 mg q12 hours
(3) Increased Oral Secretions:
• Hyoscine-N-Butylbromide 20 mg IV q6-8 hours
• Hyoscine-N-Butylbromide 10-20 mg PO/NGT q6-8 hours
h Actively
Dying
The hours or days preceding imminent death during which time the patient’s physiologic functions wane
The patient may exhibit signs and symptoms of near death.

(1) Long pauses in breathing: patient’s breathing patterns may also be very irregular
(2) Blood pressure drops significantly (continuous steady decline of >20 mmHg)
(3) Patient’s skin changes color (mottling) and their extremities may feel cold to the touch
(4) Patient is in a coma, or semi-coma, or cannot be awoken
(5) Urinary and bowel incontinence and/or decrease in urine; urine may also be discolored
(6) Hallucinations, delirium, and agitation
(7) Build-up of fluid in the lungs, which may cause unusual gurgling sounds
i Comfort Measures
Referes to medical treatment of a dying person where the natural dying process is permitted to occur whole ensuring maximum comfort. It includes attention to the psychological and spiritual needs of the patient
and support for both the dying patient and the patient’s family. Comfort measures is commonly referred to as “comfort care” by the general public.
jBereavement Support – After the patient’s death, a member of the health care team should contact the family caregiver(s) to offer condolences and answer questions of the family
POSTMORTEM CARE
52
Post-Mortem Care
53

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ALGORITHMS FOR COVID-19

Triage and Management Discharge and

Emergency Department and Transport Figure G1-5

Use of Personal Protective Equipment (PPE) Figure I

Advanced Care Planning Figure J

End-of-life Care Figure K

Post-mortem Care Post-Mortem Care Guidelines

1 Symptoms: cough OR sore throat OR fever OR diarrhea OR loss of taste or smell

Recovered May return to

dRefer to workplace guidelines

1. DOLE-DTI Joint Memorandum Circular 20-04-A (August 15, 2020)

Rapid antigen Y Y Y MILD

Isolate at LIGTAS Quarantinec the

b LIGTAS COVID Center - Contacts shall be provided with

c Home Quarantine - All members of the household must strictly Provide 12

e Improvement of clinical status:

aImprovement of clinical status

Recovered MILD May return to

dTypical chest imaging findings of COVID-19: Usual precautions

bInvestigationalDrugs For Moderate COVID-19

Recovered May return to

From Figure E1 FOOTNOTES:

1 aImprovement of clinical status

eReferto workplace guidelines

See Figure G2 See Figure G1

Rapid Antigen Do test;

See Figure J for Advance Care Planning

2 Guidelines on Advance Directives (DNR)

3 2. Free and informed decision for DNR made by competent patient

4. Without patient’s or proxy’s decision, the medical team can decide

Patient develops See Figure F2.3

Irreversible Y See Figure H for

Y See Figure I for

Initiate CPR with On mechanical Y

Do early Continue CPR on

See Figure L for 27

a dIntensive pulmonary care bundle

bSystemic Inflammatory Response Syndrome (SIRS) Criteria

Recovered May return to

See Figure L for

*Primary transportation: Transfer of a patient from the site of an

Keep all windows

HCW in an Return to Navigation

Moderate Risk High Risk Very High Risk

Level 2 PPEa,b Level 3 PPEa,b Level 4 PPEa,b

Low Risk Level 1b,c

Respiratory Distress Y Continue current

Can start opioid

Treat other Maximize all

* Do opioid precaution monitoring for opioid-naïve patients

d Opioid Infusion Principles

e Medications for Agitation/ Delirium

The patient may exhibit signs and symptoms of near death.

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