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Overview

This guideline is intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. It is not meant to replace clinical judgement or specialist consultation but rather to strengthen frontline clinical management and the public health response.

The direction and strength of recommendations are presented using the following symbols: 

[✓] Denotes a strong recommendation or a best-practice statement in favour of an intervention.

[X] Denotes a recommendation or a best-practice statement against an intervention.

View this summary online at guidelines.co.uk/455857.article.

COVID-19 care pathway

Algorithm 1: COVID-19 care pathway

WHO Algorithm 1- COVID-19 care pathway

Note: This COVID-19 care pathway describes a coordinated and multidisciplinary care pathway that a patient enters after s/he is screened for COVID-19 and becomes a suspect COVID-19 case, and follows the continuum of their care until release from the pathway. The objective is to ensure delivery of safe and quality care while stopping onwards viral transmission. All others enter the health system in the non-COVID-19 pathway. For the most up-to-date technical guidance related to the COVID-19 response, visit WHO Country and Technical Guidance.

[✓] A COVID-19 care pathway should be established at local, regional, and national levels. COVID-19 care pathways are for persons with suspected or confirmed COVID-19.

[✓] Discontinue transmission-based precautions (including isolation) and release from COVID-19 care pathway as follows:

  • criteria for discharging patients from isolation (i.e discontinuing transmission-based precautions) without retesting:
    • for symptomatic patients: 10 days after symptom onset, plus at least 3 additional days without symptoms (including without fever and without respiratory symptoms)
    • for asymptomatic patients: 10 days after positive test for SARS-CoV-2
  • countries may choose to continue to use testing as part of the release criteria. If so, the initial recommendation of two negative polymerase chain reaction (PCR) tests at least 24 hours apart can be used
  • some patients may experience symptoms beyond the period of infectivity. See the section: ‘Care of COVID-19 patients after acute illness’
  • the clinical pathway needs to be clearly outlined by countries to follow each patient until outcome, including full recovery. Discharge criteria from clinical care need to take into account the patient’s condition, disease experience, and other factors
  • release from the COVID-19 care pathway is not the same as clinical discharge from a facility or from one ward to another. For example, some patients may still require ongoing rehabilitation, or other aspects of care, beyond release from the COVID-19 care pathway, based on clinical needs in the COVID-19 care pathway. If release from the COVID-19 care pathway coincides with clinical discharge, then several clinical considerations, such as medication reconciliation, plan for follow up with clinical provider in place, review of routine immunisation status, among others, should be taken into account.

Screening, triage, and clinical assessment

Table 1: Symptoms associated with COVID-19

Commonly experienced symptoms

Fever

Cough

Fatigue

Anorexia

Shortness of breath

Myalgias

Other non-specific symptoms

Sore throat

Nasal congestion

Headache

Diarrhoea

Nausea and vomiting

Anosmia

Ageusia

Additional neurological manifestations

Dizziness

Agitation

Weakness

Seizures

Findings suggestive of stroke (e.g. trouble with speech or vision, sensory loss, or problems with balance in standing or walking)

Atypical symptoms that may be experienced by older people and immunosuppressed patients

Fatigue

Reduced alertness

Reduced mobility

Diarrhoea

Loss of appetite

Confusion

Absence of fever

Overlapping symptoms

Dyspnoea, fever, gastrointestinal symptoms, or fatigue due to physiological adaptations in pregnant women, adverse pregnancy events, or other diseases

Children might not have reported fever or cough as frequently as adults

Presenting signs and symptoms of COVID-19 vary

[✓] Screening all persons at the first point of contact with the health system is recommended, in order to identify individuals that have suspected or confirmed COVID-19.

[✓] In community settings, community health workers should continue to follow usual protocols for recognition and treatment of other common illnesses and danger signs while activating the COVID-19 care pathway (including for referral as needed) for suspect cases.

[✓] At a health facility, after screening and isolation, triage patients with suspected COVID-19 using a standardised triage tool and evaluate the patient to determine disease severity.

  • Patients with mild and moderate illness may not require emergency interventions or hospitalisation; however, isolation is necessary for all suspect or confirmed cases to contain virus transmission. The decision to monitor a suspect case in a health facility, community facility, or home should be made on a case-by-case basis. This decision will depend on the clinical presentation, requirement for supportive care, potential risk factors for severe disease, and conditions at home, including the presence of vulnerable persons in the household
  • Early identification of patients at risk for and with severe disease allows for rapid initiation of optimised supportive care treatments and safe, rapid referral to a designated destination in the COVID-19 care pathway (with access to oxygen and respiratory support)
  • Known risk factors for rapid deterioration, severe disease, and/or increased mortality are:
    • older age (> 60 years)
    • non-communicable diseases such as diabetes, hypertension, cardiac disease, chronic lung disease, cerebrovascular disease, dementia, mental disorders, chronic kidney disease, immunosuppression, obesity, and cancer
    • in pregnancy: increasing maternal age, high body mass index, non-white ethnicity, chronic conditions, and pregnancy-specific conditions such as gestational diabetes and pre-eclampsia
  • Patients with one or more of these risk factors should be monitored closely for deterioration, preferably in a health facility
  • Some patients develop severe pneumonia and require oxygen therapy, and a minority progress to critical disease with complications such as respiratory failure or septic shock
  • COVID-19 confirmation needs to be made prior to determining severity, particularly in children, for whom the differential diagnosis for respiratory distress is particularly important
  • Children with suspected or confirmed COVID-19 infection should be kept together with caregivers wherever possible (if caregivers also have suspected or confirmed COVID-19 infection), and cared for in child-friendly spaces, taking into account specific medical, nursing, nutritional, and mental health and psychosocial support needs of children.

 

Infection prevention and control

[✓] Screening and triage for early recognition of suspected COVID-19 patients and rapid implementation of source control measures is recommended. Screen all persons at first point of contact in the health facility to allow for early recognition, followed by their immediate isolation/separation.

[] Apply standard precautions for all patients.

[] Apply contact and droplet precautions for suspected or confirmed COVID-19 patients.

[] Apply airborne precautions when performing aerosol-generating procedures.

Management of mild COVID-19: symptomatic treatment 

[] It is recommended that patients with suspected or confirmed mild COVID-19 be isolated to contain virus transmission according to the established COVID-19 care pathway. This can be done at a designated COVID-19 health facility, community facility, or at home (self-isolation).

[] It is recommended that patients with mild COVID-19 be given symptomatic treatment such as antipyretics for fever and pain, adequate nutrition, and appropriate rehydration.

[] Counsel patients with mild COVID-19 about signs and symptoms of complications that should prompt urgent care.

[X] Antibiotic therapy or prophylaxis should not be used in patients with mild COVID-19.

Management of moderate COVID-19: pneumonia 

[] It is recommended that patients with suspected or confirmed moderate COVID-19 (pneumonia) be isolated to contain virus transmission. Patients with moderate illness may not require emergency interventions or hospitalisation; however, isolation is necessary for all suspect or confirmed cases.

For recommendation on the management of severe and critical COVID-19, and prevention of complications in hospitalised and critically ill patients with COVID-19, refer to the full guideline.

Other acute/chronic infections in patients with COVID-19

[X] For patients with suspected or confirmed mild COVID-19, WHO recommends against the use of antibiotic therapy or prophylaxis. 

[X] For patients with suspected or confirmed moderate COVID-19, it is recommended that antibiotics should not be prescribed unless there is clinical suspicion of a bacterial infection. 

[] It is recommended for patients with suspected or confirmed severe COVID-19, the use of empiric antimicrobials to treat all likely pathogens, based on clinical judgement, patient host factors, and local epidemiology, and this should be done as soon as possible (within 1 hour of initial assessment if possible), ideally with blood cultures obtained first. Antimicrobial therapy should be assessed daily for de-escalation.

[] Treatment of other coinfections may be based on a laboratory-confirmed diagnosis or epidemiological and clinical criteria.

Associated neurological and mental manifestations

Delirium

[] In patients with COVID-19, it is recommended that measures to prevent delirium, an acute neuropsychiatric emergency, be implemented, and patients be evaluated using standardised protocols for the development of delirium. If detected, then immediate evaluation by a clinician is recommended to address any underlying cause of delirium and treat appropriately.

Stroke

[] Patients presenting with rapidly developing neurological symptoms suggestive of stroke should be evaluated as soon as possible and standard stroke protocols should be followed including systemic thrombolysis and/or intra-arterial thrombectomy, if indicated. Signs and symptoms of stroke can include weakness of limbs or face, sensory loss, speech difficulties, impairment of vision, ataxia, confusion, or decreased consciousness. Standard infection prevention and control measures must be followed during the clinical evaluation, neuroimaging, or procedures for patients with stroke.

Mental health and psychosocial support

[✓] It is recommended that basic mental health and psychosocial support be provided for all persons with suspected or confirmed COVID-19 by asking them about their needs and concerns, and addressing them.

[✓] Prompt identification and assessment for anxiety and depressive symptoms in the context of COVID-19 is recommended, and to initiate psychosocial support strategies and first-line interventions for the management of new anxiety and depressive symptoms.

[✓] Psychosocial support strategies are recommended as the first-line interventions for management of sleep problems in the context of acute stress.

Non-communicable diseases and COVID-19

[✓] When caring for patients with suspected and confirmed COVID-19 that have underlying non-communicable diseases, the recommendation is to continue or modify previous medical therapy according to the patient’s clinical condition.

[✓] Antihypertensive drugs should not routinely be stopped in patients with COVID-19, but therapy may need to be adjusted based on general considerations for patients with acute illness, with particular reference to maintaining normal blood pressure and renal function.

Rehabilitation for patients with COVID-19

[✓] Patients with COVID-19, should be provided with education and support for the self-management of breathlessness and resumption of activities, both in a hospitalised and a non-hospitalised setting caring for COVID-19. 

[✓] For patients who have been discharged from the hospital or patients who have been managed at home and experience persistent symptoms and/or limitations in functioning, screen for physical, cognitive, and mental impairments, and manage accordingly.

[✓] Provide individualised rehabilitation programmes from subacute to long term according to patient needs. The prescription and provision of rehabilitation programmes should be guided by persistent symptoms and functional limitations.

COVID-19 during and after pregnancy

[✓] All pregnant women with history of contact with a person with confirmed COVID-19 should be carefully monitored considering asymptomatic transmission of COVID-19.

[✓] Pregnant or recently pregnant women with suspected or confirmed mild COVID-19 may not require acute care in hospital, unless there is concern for rapid deterioration or an inability to promptly return to hospital, but isolation to contain virus transmission is recommended, and can be done at a health facility, community facility or at home, according to established COVID-19 care pathways.

[✓] Pregnant or recently pregnant women with moderate or severe COVID-19 require acute care in the hospital, as there is concern for rapid deterioration that may warrant supportive care for severe respiratory morbidity, and/or interventions to improve maternal and foetal survival.

[✓] Mode of birth should be individualised, based on obstetric indications and the woman’s preferences. WHO recommends that induction of labour and Caesarean section should only be undertaken when medically justified and based on maternal and foetal condition. COVID-19 positive status alone is not an indication for Caesarean section.

[✓] Pregnant and recently pregnant women who have recovered from COVID-19 and been released from the COVID-19 care pathway, should be enabled and encouraged to receive routine antenatal, postpartum, or post-abortion care, as appropriate. Additional care should be provided if there are any complications.

Infants and young children of mothers with COVID-19

[✓] It is recommended that mothers with suspected or confirmed COVID-19 should be encouraged to initiate and continue breastfeeding. From the available evidence, mothers should be counselled that the benefits of breastfeeding substantially outweigh the potential risks of transmission.

Care of older people with COVID-19

[✓] It is recommended that older people be screened for COVID-19 at the first point of access to the health system, be recognised promptly if they are suspected to have COVID-19, and treated appropriately according to established COVID-19 care pathways. This should occur in all settings where older people may seek care, included but not limited to facility-based emergency units, primary care, pre-hospital care settings, and long-term care facilities.

[✓] Identify if there is an advance care plan for patients with COVID-19 (such as desires for intensive care support) and respect their priorities and preferences. Tailor the care plan to be in line with patients’ expressed wishes and provide the best care irrespective of treatment choice.

[✓] A review of medication prescriptions to reduce polypharmacy and prevent medicine interactions and adverse events for those being treated with COVID-19 is recommended.

[✓] Ensure multidisciplinary collaboration among physicians, nurses, pharmacists, physiotherapists, occupational therapists, social workers, mental health and psychosocial providers, community workers, and other healthcare professionals in the decision-making process to address multimorbidity and functional decline.

For recommendations on palliative care and COVID-19, refer to the full guideline.

Care of COVID-19 patients after acute illness

[✓] Patients who have had suspected or confirmed COVID-19 (of any disease severity) who have persistent, new, or changing symptoms, should have access to follow-up care.

Recognition

  • All patients (and their caregivers) with COVID-19 should be counselled to monitor for resolution of signs and symptoms. If any one or more of these persist, or patient develops new or changing symptom, then to seek medical care according to national (local) care pathways
  • This includes counselling about acute life-threatening complications, such as pulmonary embolism, myocardial infarction, dysrhythmias, myopericarditis and heart failure, stroke, seizures, and encephalitis, for which they should seek emergency care
  • Patients with severe and critical COVID-19 may develop post-intensive care syndrome, with a range of impairment including (but not limited to) physical deconditioning, cognitive, and mental health symptoms.

Management

  • National (local), coordinated care pathways should be established that can include primary care providers (i.e. GPs), relevant specialists, multidisciplinary rehabilitation professionals, mental health and psychosocial providers, and social care services
  • Management should be tailored according to patient needs and be coordinated
  • Management interventions include addressing promptly life-threatening complications. For non-life-threatening complications, management may entail education, advice on self-management strategies (i.e. breathing techniques, pacing), caregiver support and education, peer-to-peer groups, stress management, stigma mitigation and home modification; prescription of rehabilitation programmes, and/or specialty management. 

For recommendations on ethical principles for optimum care, reporting and coding (mortality and morbidity), and clinical research during the COVID-19 pandemic, refer to the full guideline.

 

Full guideline: 

World Health Organization. COVID-19 clinical management: living guidance. WHO, 2021. Available at: who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1

Published date: 25 January 2021.