Strengthening Referral System

during COVID-19 Pandemic

Strengthening Referral System during COVID-19 Pandemic

Dr. Roy Gavino

Local Service Delivery Advisor
USAID’s ReachHealth Project
 • Strengthening Referral System during COVID-
Sessions 19 Pandemic
• Early Identification and Prevention of COVID-
19 Transmission during Triage
 Suspect

• Individuals with influenza-like symptoms who have had

either a travel history to a place with known local
transmission, or close contact with a confirmed or probable
COVID-19 patient 14 days before onset of symptoms
• A patient with fever, cough, or shortness of breath (SOB)
and is either 60 years old or older, has a preexisting medical
Classification of condition, with high risk pregnancy, or a healthcare worker.
• Someone with sudden acute respiratory infection (SARI)

COVID-19 who needs hospitalization

Cases
Reference: DOH AO 2020-0013 Probable

• Tested but result is uncertain

• Tested in an unofficial laboratory

Confirmed

• Result of RT-PCR test done in certified lab came out positive

 COVID-19 Health Care Provider Network
Type of Facility Example Function/Services
Primary Care RHUs, health centers, • Main navigators/first contact
Facilities out-patient clinics
Temporary Community Isolation • Shall cater to asymptomatic cases with close contact (quarantine), and mild
Treatment and Unit (CIU), LIGTAS symptomatic suspect, probable and confirmed cases (community isolation)
Monitoring COVID and Mega • May serve as step-down facilities for clinically recovered patients
Facilities (TTMF) LIGTAS COVID Centers completing quarantine period
COVID-19 Designated COVID-19 • Shall prioritize suspect, probable, or confirmed COVID-19 cases with severe
Referral referral hospitals or critical symptoms, as well as patients ≥ 60 old and/or with co-
Hospitals morbidities
• Non-COVID-19 cases received shall be stabilized and transferred to another
facility for continued management
COVID-19 Level 2 and 3 public • Shall accept and manage suspect, probable and confirmed COVID-19 cases
Accepting and private hospitals • With individual isolation rooms
Hospitals • Cohorting of patients may be allowed only among confirmed cases
Step-down Care Level 1 hospitals, • Shall accept clinically recovered cases or those whose condition have
Facility infirmary, and TTMF improved.

References: DOH DM 2020-0178; DOH DM 2020-0161; DOH MC 2020-0020

 Type of Patient Recommended Facility
All patients • Primary care facility for triaging, or via
telemedicine/teleconsultation, if available

Patient-Facility Asymptomatic with close

contact
•
•
Home quarantine for 14 days or
Temporary Treatment and Monitoring
Matching Symptomatic, mild •
Facility for 14-day quarantine
Temporary Treatment and Monitoring
classified as suspect, Facility for 14-day isolation (preferred) or
probable, or confirmed • Level 1 Hospital or Infirmary or
COVID-19 case • Home Isolation (with clearance from
attending physician)
Symptomatic, severe or • COVID-19 Referral Hospital or
critical • COVID-19 Accepting Level 2 or 3 Hospital

Symptomatic, mild with

any of the two:
• ≥ 60 years old
• With comorbidities
Clinically recovered • Level 1 Hospital or Infirmary
suspect, probable, or • Temporary Treatment and Monitoring
confirmed COVID-19 case Facility selected for Step-down care
awaiting completion of
quarantine period
Patient Flow in
HCPN
Reference: DOH DM 2020-0178

Critical Step-down
Severe care
Contact tracing in the Comorbidities COVID-19 Referral Hospital L2/L3 Hospital
community c/o BHERTS ≥60 years old

Primary care facility L1 and Infirmary CIU/TTMF

Suspect, probable, Individual rooms for suspect and
confirmed case w/ probable case, cohorting for confirmed severe
mild symptoms symptoms

Asymptomatic
with exposure
(close contact)

Home Quarantine CIU/TTMF Mild symptoms

General Patient Pathway in HCPN Under the New Normal
Reminders on Patient Triage
DOH DM 2020-0123

TRIAGE SHOULD BE IDEALLY OTHER RESPIRATORY TRIAGE OFFICERS SHOULD TRIAGE OFFICERS SHALL IF PATIENTS ARE IN A QUEUE
CONDUCTED IN AN HYGIENE SUPPLIES, TRASH WEAR THE APPROPRIATE CONDUCT A COMPLETE (SURGE OF PATIENTS),
ISOLATION ROOM WITH BINS, AND HAND HYGIENE PERSONAL PROTECTIVE HISTORY AND PHYSICAL SEPARATE THE “SICK” FROM
NEGATIVE PRESSURE FACILITIES SHOULD BE EQUIPMENT. EXAMINATION, AND DECIDE THE “WELL” PATIENTS BY 6
AVAILABLE INSIDE THE WHETHER A PATIENT FEET (2 METERS), AND
ROOM. FULFILLS THE CASE ENSURE PATIENTS ARE AT
DEFINITION OR CRITERIA LEAST 3 FEET (1 METER)
FOR THE SPECIFIC APART FROM EACH OTHER.
RESPIRATORY INFECTION OR
PANDEMIC OR OUTBREAK
POTENTIAL (RIPOP)
 • Strengthening Referral System during COVID-
19 Pandemic
• Early Identification and Prevention of COVID-
Sessions 19 Transmission during Triage
• Guidelines on Expanded Testing for COVID-19
• Interim Guidelines on the Continuous
Provision of Maternal Health Services
• Respectful Maternity Care
Early Identification and Prevention of COVID-19
Transmission during Triage

Dr. Angeli Conti-Lopez

Technical Advisor
USAID’s ReachHealth
Project
This triage SOP should be used in addition to
and not as a replacement to routine clinical
triage already in place in healthcare facilities

Some slides contain additional information in the Slide Notes.

cdc.gov/coronavirus
What is triage?
 The sorting out and classification of patients to determine priority of need
and proper place of treatment  

 For COVID-19 outbreak, triage is particularly important to separate patients

likely to be infected with the virus that causes COVID-19

 Effective triage can prevent transmission of the virus that causes COVID-19
to patients and healthcare workers (HCWs)
What healthcare facilities (HCFs) can do

 Communicate with patients before arriving for triage 

 Set up and equip triage
 Set up a “respiratory waiting area” 
 Establish triage process
 Train staff on infection prevention and control
measures including proper use of personal
protective equipment

WPRO: The COVID-19 risk communication package for healthcare facilities

Communicate with patients before arriving to HCF

 Establish a hotline for patients to call before

arrival to HCF to determine the need for a visit

 Inform general public through mass media

about availability of a hotline and the signs and
symptoms of COVID-19 that require care

 Consider telemedicine (cell phone
videoconference or teleconference) for clinical
support
Set up and equip triage

 Strategically place clear signs

directing patients with respiratory
symptoms to immediately report to the
registration desk 

 If possible, consider having a separate

registration desk for patients coming in
with respiratory symptoms
– Ensure the signs direct patients to
the dedicated registration desk
Set up and equip triage
 Hand hygiene facilities
 PPE for staff
 Surgical mask for coughing
patients
 Thermal gun
 Screening questionnaire
 Algorithm for triage
 Waste disposal and disinfection
equipment
 Physical distancing more than
1-2 m

✔ Outside ✔ Tent ✔ Completely separate COVID-19and others

WPRO: The COVID-19 risk communication package for healthcare facilities

Visual alerts

Place alerts at the entrance of the facility and in

strategic areas (waiting areas or elevators) 

Alerts should cover:

 Cough etiquette
 Disposal of contaminated items
 Hand hygiene
Set up a “respiratory waiting area” 

A separate, well-ventilated area where

patients at high risk for COVID-19
can wait
This area should have:
 Benches, stalls or chairs separated
by at least one-meter distance ​
 Dedicated toilets and hand
hygiene stations​
 Paper tissue, alcohol-based hand
sanitizer, and trash bin with lid​
 Clear signs informing the location of
“respiratory waiting areas” 
Triage process

 Assign dedicated clinical staff (physicians or nurses) for physical

evaluation of patients presenting with respiratory symptoms at
triage
 Train administrative personnel working in the reception area

Standardized triage algorithm

 No or limited COVID-19 community transmission
 Widespread COVID-19 community transmission
Triage process
 Follow the appropriate triage algorithm
 Give a facemask to patients with respiratory symptoms
 Immediately isolate/separate patients at high risk for COVID-19 in:
– single-person rooms with doors closed
OR
– designated “respiratory waiting areas”
 Limit the number of accompanying family members in the waiting area
Cleaning and disinfection of triage area

 Clean and disinfect triage area, including “respiratory waiting areas,”

at least twice a day
 Focus on frequently touched surfaces
 Disinfect with 0.5% (5000ppm) chlorine
OR
 70% alcohol for surfaces that do not tolerate chlorine
What Healthcare Workers Can Do
Infection prevention and control
precautions
 Adhere to Standard Precautions
 Be trained on and familiar with Contact and Droplet
Precautions
 Ensure that environmental cleaning and disinfection
procedures are followed consistently and correctly
 Stay home if develop fever and/or respiratory
symptoms (cough, shortness of breath) 
Personal Protective Equipment (PPE)
 HCWs who do not come in contact with suspected or confirmed COVID-19
patients
Physical barrier AND No physical barrier AND
Physical distance of at least 1 m Physical distance is not feasible

Facemask
Glass or plastic barrier

No PPE required Use mask and eye protection

Personal Protective Equipment (PPE)
 HCWs who come in contact with suspected or confirmed COVID-19 patients
should wear appropriate PPE

Conducting examinations of patients

with respiratory symptoms
Important Measures During Periods of
COVID-19 Community Transmission
Strategies to avoid overcrowding at triage and
preserve PPE
 Cancel non-urgent outpatient visits to ensure enough HCWs are available to
provide support for COVID-19 clinical care, including triage services
– If outpatient visit is critical (such as immunization of infants or pre-natal care
for high-risk pregnancy), identify separate/dedicated entrance for these
patients
– Reinforce telemedicine or other alternative to face-to-face visit
 Postpone or cancel elective procedures and surgeries to minimize exposures
and to preserve PPE for HCWs caring for COVID-19 patients
 Expand hours of operation, if possible, to limit crowding in triage during
peak hours
Thank you!
USAID’s ReachHealth Project
Implemented by RTI International in partnership with: