Transcript
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Preparation and Resumption of Clinic Services After

Enhanced Community Quarantine:

A Consensus Statement by the PAFP Committee on

Standards of Practice and Ethics

Cheridine Oro- Josef, MD

Chair

Lyndon Patrick A. Dayrit, MD Florentino M. Berdin, Jr., MD

Co- Chairs

Members: Glenn Q. Mallari, MD

Ellen May G. Biboso, MD Arlette Sanchez- Samaniego, MD

Noel M. Laxamana, MD Faye Clarice M. Maturan, MD

Ruth Mary S. Pada, MD Maria Elinore Alba Concha, MD

Annabelle C. Fuentes, MD Alimyon Abilar- Montolo, MD Rhodora Rhea Polestico, MD Juan Paulo C. Maturan, MD

Clarisse P. Floresca, MD

May 2020

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Preparation and Resumption of Clinic Services After

Enhanced Community Quarantine: A Consensus Statement

by the PAFP Committee on Standards of Practice and Ethics

The Philippine Academy of Family Physicians, Inc.

Statement of Recommendations

Readiness of Health Care Staff

Statement 1: Family physicians and their staff should prepare themselves mentally, physically, and

emotionally before resuming clinic services. Prior to starting every clinic day, physicians and their staff

should take their temperature and check for respiratory symptoms.

Statement 2: All clinical staff should be properly trained on proper use of PPEs, clinic disinfection,

infection control, and other safety procedures.

Statement 3: Family Physicians should design an office management and operations plan that includes

triage, patient flow, treatment, and other patient care protocols including strict implementation of

infection prevention and control procedures, management of PPE supplies, and potential staff

shortages.

Statement 4: The clinic staff must inform their patients of the changes that may result from the new

management and operations plan that will be made in the facility.

Clinic Procedures, Disinfection and Infection Control

Statement 5: After undergoing proper triage, nonCOVID-19 patients entering the clinic should use

hand sanitizer and step on a foot bath or pad soaked in chlorine or any approved disinfectant solution

at the entrance. All clinic staff, patients and accompanying persons should be wearing a mask inside

the clinic. They should be instructed to avoid touching their face or mask and to wash their hands

immediately before and after if it cannot be avoided.

Statement 6: Appropriate visual alerts or educational posters regarding infection control, proper

handwashing, coughing and sneezing etiquette should be visible inside the clinic.

Statement 7: The clinic facility must have infection prevention and control measures that adhere to

international and local standards.

Statement 8: After appropriate triaging, a family physician when attending to a patient should wear a

mask, single use gloves, and eye protection. Apron or gown is optional. It is up to the discretion of the

family physician whether or not to use a higher level of protection based on his risk assessment of the

clinic environment, and available resources.

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Clinical Services

Statement 9: As much as possible, family physicians should continue all primary care services in the

clinics. However, it is advisable to initially limit the service to non-COVID-19 (suspect or diagnosed)

patients. Clinics should follow the guidelines set forth by the Department of Health and refer patients

needing COVID-19 assessment and management to the appropriate facilities.

Statement 10: Patients who sought consult and whose symptoms were resolved may choose not to

come back for follow-up. Patients with chronic diseases may be followed-up at longer intervals if their

illness is stable.

Statement 11: Referrals for further assessment, diagnostic tests, or other procedures not available in

the clinic must first be coordinated with the referral center or site.

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Philippine Academy of Family Physicians

Officers and Board of Directors 2020-2021

President Maria Victoria Concepcion P. Cruz, MD

Vice-President Karin Estepa-Garcia, MD

Secretary Lynne Marcia H. Bautista, MD

Treasurer Jane Eflyn Lardizabal-Bunyi, MD

Immediate Past President Policarpio B. Joves, Jr. MD

National Directors Limuel Anthony B. Abrogena. MD

Disi Yap-Alba, MD

Ryan Jeanne V. Ceralvo, MD

Ferdinand S. De Guzman, MD

Noel L. Espallardo, MD

Aileen T. Riel-Espina, MD

Ricardo S. Guanzon, MD

Cheridine Oro-Josef, MD

Josefina S. Isidro-Lapeña, MD

Anna Guia O. Limpoco, MD

Leilanie Apostol-Nicodemus, MD

Regional Directors Rhodora M. Falcon-Pesebre, MD (North Luzon)

Ceasar V. Palma, MD (South Luzon)

Jimmy Jay F. Bullo, MD (Visayas)

Ricardo B. Audan, MD (Mindanao East)

Belinda Cu-Lim, MD (Mindanao West)

Josephine A. Chikiamco-Dizon, MD (NCR)

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Preparation and Resumption of Clinic Services After

Enhanced Community Quarantine: A Consensus Statement

by the PAFP Committee on Standards of Practice and Ethics

The Philippine Academy of Family Physicians, Inc. Background

Family medicine practice in the Philippines is diverse. One might find family medicine specialists providing health care in small barrios in the provinces, in busy urban communities, markets, malls, and in hospital-affiliated satellite medical clinics. Others are in a multidisciplinary practice in a hospital while some prefer to man the emergency rooms, out-patient departments of private hospitals, schools, and corporate offices. Most family medicine practitioners involved in government practice oversee barangay health offices and community healthcare facilities, while those in tertiary hospitals serve in out-patient consults and triage, and hence are now frontline physicians in this COVID 19 pandemic.

Family medicine practitioners both in private and in government settings are at the frontline of patient care and are the most accessible healthcare professionals to Filipino families next to barangay health workers. At the onset of this COVID 19 pandemic, it has become their major responsibility to screen high risk groups, identify probable cases, prevent spread, and educate patients. Most patients visit their primary care physicians first before going to hospitals for care. During the Enhanced Community Quarantine (ECQ), most private and out-patient clinics temporarily stopped operations and physicians made use of other means of communication to serve their patients. Once the ECQ is lifted, physicians will now be facing the challenges of setting up their own clinics to adapt to the new normal.

This consensus guideline was developed for Family physicians in a private practice, solo or multispecialty clinics. We recommend that family physicians resume their clinical practice and adhere to these guidelines. However, since the course and pathophysiology of the virus is evolving, these recommendations are subject to change based on new information that will be gathered. The recommendations are based on available evidence and its applicability and relevance to local family practice were considered.

Methodology The Standards of Medical Practice and Ethics Committee of the Philippine Academy of Family Physicians assigned an expert to review the published medical literature to identify, summarize and operationalize the evidences in clinical publication on how to resume clinic practice for primary care physicians both in the community and hospital setting. The term “COVID-19” was used to search in PubMed and was limited to “guidelines”. Other medical literature and local recommendations were also considered. All relevant articles were reviewed and recommendations were summarized into statements. Each statement was updated with further search and review of articles prioritizing the following type of clinical publications: meta-analysis, randomized controlled and clinical trials. The statements were then reviewed by members of the Committee and submitted to the PAFP COVID-19 Task Force for further review. The statements were disseminated to PAFP chapters and members and other stakeholders.

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Dissemination was also done through publication in the PAFP website and the Filipino Family Physicians Journal.

The following consensus statements were designed to guide family medicine specialists and all primary care physicians on strategies they can use to prepare themselves, their staff and their clinics for the resumption of outpatient clinic services and adequately protect themselves and their patients. While family physicians are advised to consider the recommendations, they should rely on their own judgement in assessing their clinic and staff are capable of implementing the recommendations.

Recommendations Readiness of Health Care Staff Statement 1. Family physicians and their staff should prepare themselves mentally, physically and

emotionally before resuming clinic services. Prior to starting every clinic day, physicians and their staff

should take their temperature and note respiratory symptoms.

During infectious disease outbreaks, healthcare workers suffer adverse emotional and

psychological reactions. With the number of morbidity and mortality rising among healthcare workers, it

has been noted that the impact of this COVID 19 crisis has been likened to war. Medical staff and affiliated

healthcare workers (considered as front liners) are under physical and psychological pressure. For many

nations this will add to an existing baseline of psychological pathology and low morale in the healthcare

sector.1 A study of 500 healthcare workers in Singapore showed that 14.5% of participants screened

positive for anxiety, 8.9% for depression, 6.6% for stress, and 7.7% for clinical concern of PTSD. The

prevalence of anxiety was higher among nonmedical health care workers than medical personnel.2

Researchers in Wuhan, China conducted a cross-sectional, geographically stratified survey of 1257

healthcare workers and found the same prevalence.3-4 From these studies, we recommend that physicians

assess themselves and consult psychologists or psychiatrists if they feel they are in need of medical

intervention. Otherwise, personal self- care and mindfulness meditations are also advised.5

Family physicians and other health staff who tested positive (Rt-PCR) should have, at least, two

negative tests prior to resumption of clinic activities. Should these tests be unavailable, the symptom-

based strategy recommended by the World Health Organization and the recommendation in the Unified

Algorithms for Return to Work shall be followed.6-7 It is also advisable for clinic Staff and other healthcare

workers to follow guidelines of DOLE and PCOM on return-to-work protocol.8

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Statement 2. All clinical staff should be properly trained on proper use of PPEs, clinic disinfection,

infection control and other safety procedures.

Increased attention should be paid to the knowledge and attitude of medical staff during CoVID19

outbreak.9 Family physician should educate staff and patients on:

• Basic information regarding coronavirus disease 2019 (COVID-19) with emphasis on how it is

transmitted and the importance of isolation and contact tracing.

• Facility policies and practices to minimize chance of exposure to respiratory pathogens including

SARS-CoV-2, the virus that causes COVID-19.

• Job-or task-specific information on preventing transmission of infectious agents, including

refresher training.

• Screening for COVID-19 symptoms and history of exposure.

• Alternative office management plans.

• How to advise patients about changes in office procedures (e.g., calling prior to arrival if the

patient has any signs of a respiratory infection and taking appropriate preventive actions) and

developing family management plans if they are exposed to CoVID-19.

Statement 3. Family Physicians should design an office management and operations plan that includes

triage, patient flow, treatment and other patient care protocols including strict implementation of

infection prevention and control procedures, management of PPE supplies and potential staff shortages.

The following should be the main content of an operations and management:10

• To prevent crowding and to allow for a one-meter distance between patients, physicians are

advised to accept consults via an “appointment only” basis. They are also encouraged to offer

telemedicine for patients whose complaints do not require close physical examination such as

otoscopy, throat and mouth exam, abdominal exam, etc. Routine appointments such as regular

laboratory monitoring may also be done via video or phone consults.

• Screen all patients requesting for an appointment using the most recent triaging algorithm

endorsed by the Department of Health so that suspect COVID-19 cases can be advised to consult

at an appropriate facility.

• Individuals, including the physician, clinic staff, patients and their companions, shall be checked for

fever (body temperature of greater than or equal to 38.0*C) prior to entering the facility so that

they may be properly reassessed for COVID-19 symptoms.

• To further limit exposure of all persons within the facility from possible asymptomatic carriers of

COVID-19, everyone must be required to wear a face mask before entering. Clinics are also advised

to make face masks available; in the event that a patient’s mask becomes soiled or broken.

• Hand hygiene facilities and equipment such as sinks, hand soap, alcohol-based hand sanitizer or

70% alcohol and paper towels must be made available and easily accessible for patient and staff

use. Ensure that “no-touch” waste receptacles are available as well.

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• All patients with fever and respiratory symptoms must be referred to COVID-19 facilities within the

physician’s area of practice. DOH COVID-19 hotlines and local barangay transportation service

contact numbers should be available and posted in the clinic.

• The physician must ensure that patients’ complete name, address, contact numbers, and date and

time of consult are kept on record in the event that contact tracing must be done in his or her

facility.5,11

Referral or Transfer of Patients

In the event that a patient is identified to be a suspect COVID-19 case despite undergoing

screening procedures prior to his or her scheduled appointment, he or she must be immediately provided

with a face mask and isolated in an area away from the rest of the patients. The physician is then advised

to notify local DOH surveillance units so that the patient may be documented, endorsed, and transferred

to an appropriate COVID-19 facility. If the DOH surveillance unit advises self-quarantine at home for the

patient and a community isolation unit is unavailable, the physician is encouraged to provide patient

education materials regarding basic COVID-19 information: self-monitoring of body temperature,

worsening of respiratory symptoms, and appropriate COVID-19 hotline numbers to contact in the event of

an emergency.11

Adequacy of PPE and Staff

Risk assessment of clinic staff and appropriate plans for clearance to work, quarantine or flexible

work schedules should be made in order to ensure the safety. Self-monitoring and reporting of symptoms

should be done by all clinic staff. If feasible, staff schedules should be arranged to ensure that staff

shortages can be avoided. The clinic is encouraged to devise a plan to procure, distribute and monitor PPE

stocks to ensure that a constant supply will be available at all times.12

Statement 4. The clinic staff must inform their patients of the changes that may result from the new

management and operations plan that will be made in the facility.

Changes may be difficult for some patients, especially to those who have grown accustomed to

the continuing care by their family physicians. Patient satisfaction to the service is often affected by

these sudden changes. For patients to adopt and accept these changes, there is a need to provide clear,

honest and valid information about COVID-19 and why changes are being done in the clinic operations.

Because of availability of information in various social media that is accessible to almost everyone, there

will be significant amount of fear and uncertainty about the situation. As family physicians, one of our

expertise is on health communication, patient education, and health behavior change.13

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____________ Figure 1. Process Flow Diagram for Non-COVID 19 Patients

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Office Set-up, Disinfection and Infection Control Statement 5. After undergoing proper triage, non-COVID 19 patients entering the clinic should use a

hand sanitizer and step on a foot bath or pad soaked in chlorine or any approved disinfectant solution at

the entrance. All clinic staff, patients and accompanying persons should be wearing at least a mask

inside the clinic. They should be instructed to avoid touching their face or mask and wash their hands

immediately before and after if cannot be avoided.

Policies on infection prevention and control measures should be communicated to all clinic staff,

patients and visitors. Waiting room chairs should be spaced at least one meter apart and upholstered

furniture and furnishings should preferably not be used. All potential fomites like fresh flowers or potted

plants, shared items like toys, newspapers or magazines should not be in waiting areas.14

If feasible, it is recommended to change doorknobs so doors can be opened or closed by using

elbows. Doors should ideally have self-closing mechanisms. As a rule, all high touch surfaces (reception

counters, doorknobs, desks, chairs, electrical switches, bed rails, wheelchairs, bathroom surfaces, etc.,

should be cleaned frequently and after each use with an approved disinfectant solution. All rooms where

appropriate, should be provided with conveniently located alcohol-based hand sanitizers, liquid soap and

paper towels. Bathrooms should have posters on proper handwashing technique.15

Proper disposal of tissues should be in “no-touch” receptacles, e.g., foot-pedal-operated lid or

open plastic-lined waste basket. Hand hygiene and proper use of personal protective equipment must be

ensured at all times. Regularly disinfect surfaces that are frequently touched. Follow standard procedures

of environmental cleaning and disinfection after seeing suspected cases. Provide adequate and

appropriate areas for disposal of contaminated PPEs and supplies. As much as possible, proper disinfection

of the examining room should be done after every patient. It is essential that both physician and staff are

trained on how to safely don, adjust, use, and doff the specific PPE that they are using.

Statement 6. Appropriate visual alerts or educational posters regarding infection control, proper

handwashing, cough or sneezing etiquette should be visible inside the clinic.

There are optimal methods to ensure behavior change, both on the individual as well as on the

community level. How recommendations are framed is important to secure adherence. The relevant

behavior changes to fight the pandemic are well known by now; hand hygiene, cough etiquette, physical

distancing, clean surfaces, avoid touching your face and many others. These recommendations will

require simple communication to raise awareness and make these behaviors a habit.13 Simple method is

to post signages in appropriate languages at the entrance and inside the office to alert all patients with

respiratory symptoms and fever to notify staff immediately. Signage in appropriate languages with

pictures to teach/remind patients about correct respiratory hygiene and cough etiquette should in

prominent areas of the clinic.

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Statement 7. The clinic facility must have infection prevention and control measures that adhere to

international and local standards.

Recognizing that COVID 19 is a respiratory virus, all rooms in all health care facilities should have

adequate ventilation to prevent air recirculation and provide one way air flow out of the room through the

use of open windows and/or exhaust fans, with the goal of achieving natural ventilation with negative air

flow. Air conditioning may be used but the room should have one-way air flow towards the outside

environment which can be achieved by installing exhaust fans. Air from toilet rooms or other soiled areas

should be exhausted directly to the atmosphere through a separate exhaust duct system.15 When feasible,

disinfect the examining area after each patient consultation.

Statement 8. After appropriate triaging, a family physician when attending to a patient should wear a

mask, single use gloves and eye protection. Apron or gown is optional. It is up to the discretion of the

family physician to use a higher level of protection base on his risk assessment of the clinic environment

and if resources are available.

The CDC recommends that for facilities that will see patients with no COVID symptoms shall be

categorized as Level 1. Physicians and their staff are advised to wear goggles or face shield, three-ply

surgical mask and single use gloves. Use of apron or gown is optional. The Philippine Society of

Microbiology and Infectious Diseases (PSMID) recommends the use of goggles or face shield, single use

apron or gown, 3-ply surgical mask and single use gloves for patients with respiratory symptoms or are

COVID suspect. This may not be necessary if the triaging is appropriate. However, it is advisable to have a

readily available set of these PPEs when the need arises.16

Medical grade coveralls should be available for use in the event that aerosol-generating

procedures need to be performed. CDC recommends that the patients to undergo aerosol-generating

procedure be placed in a negative pressure room and that the physician or staff members involved wear

goggles/ face shields, gowns, N95 respirators and gloves. The option to use transparent or acrylic boxes

depends on the physician’s assessment of the usual clinical cases seen. While minimal physical

examination is recommended, the examining bed should be covered by disposable plastic which should be

changed after every patient use. All fixtures touched by patients should be properly disinfected and

cleaned every after individual consult. Minor surgeries and procedures are discouraged. However, if

adequate disinfection and preparation is observed, procedures may be done at the discretion of the

physician. Consider designing and installing engineering controls to reduce or eliminate exposures by

shielding staff and other patients from potentially infected individuals. In most government and private

hospitals, a triage area is designated to screen patients, hence, physicians who only see non- COVID

patients may use Level 2 PPE’s (cap, goggles or face shield, N95 mask and gloves).17

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Clinical Services Statement 9. As much as possible, family physicians should continue all primary care services in the

clinics. However, it is advisable to first limit the service to non-COVID-19 (suspect or diagnosed) patients.

Patients needing COVID-19 assessment and management should be referred to appropriate facilities and

follow the guidelines set forth by the Department of Health.

The use of telehealth and remote care services are becoming important in the safe management

of patients in light of the COVID-19 pandemic. It is also becoming relevant in the delivery of continuing

health care to the population. This is especially relevant for those patients with chronic conditions

requiring follow-up consultation and management. It is recommended that in the absence of a consensus

guideline on remote care in the Philippines, telehealth should be limited to the following services:18-19

• Triaging and referral

• Appointment system for direct consultation

• Diagnostic result interpretation

• Remote patient monitoring tool, when available

• Patient education and advice and

• Documentation of patient medical record

Patient confidentiality and privacy, in relation to existing laws and the Data Privacy Act shall be

followed in the implementation of telehealth. There is a need to make difficult decisions to balance the

demands of responding directly to COVID-19, while simultaneously engaging in strategic planning and

coordinated action to maintain essential health service delivery, mitigating the risk of system collapse.

Previous outbreaks have demonstrated that when health systems are overwhelmed, mortality from

vaccine-preventable and other treatable conditions can also increase dramatically.20

Basic Primary Care services may be resumed with appropriate consideration depending on

vulnerable population. As such, the following recommendations are directed towards more specific

patient needs.21

Immunization

The Department of Health has issued interim guidelines regarding immunization schedule in

March 2020. Routine immunization of newborns and infants up to 12 months and selective vaccination of

defaulters under 5 year of age shall be maintained as long as the provision of service is aligned with

national guidelines on infection prevention and control. Immunization should be done on a per

appointment schedule and if possible in a separate area in the clinic or during separate and dedicated

schedule within the week following the guiding principles below.22

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Guiding principles for immunization program during the COVID-19 pandemic:

• Previous statements on COVID-19 infection prevention measures in this consensus guideline

should be followed during immunization sessions.

• Prioritize primary series vaccinations especially for measles-rubella- or poliomyelitis-containing

vaccines and other combination vaccines.

• Avoid mass vaccination campaigns until the COVID-19 situation resolves.

• Vaccinate newborns (as per the national immunization schedule) in maternity hospitals.

• Prioritize pneumococcal and seasonal influenza vaccines for the vulnerable population groups.

• Delay introduction of any new vaccine/s in the national immunization schedule.

• Communicate clearly to the community and healthcare professionals the rationale for inclusion of

immunization as one of the priority health services during the COVID-19 pandemic and the

benefits of vaccination.

Child Health

Consider scheduling well-visits and sick visits at different times in a day or in different days. For

practices that have multiple sites, consider using one location for well-visits and a different location for

sick visits again utilizing telemedicine to avoid face to face consultations and increase practice capacity.23

Maternal Health

There is a shortage of evidence about rationalizing visit numbers, but evidence from lower and

middle income countries suggests that attendance at five visits or less is associated with an increased risk

of perinatal mortality (RR 1.15; 95% CI 1.01 to 1.32, three trials). A minimum of six face-to-face (physical)

antenatal consultations is therefore advised. There is no appropriate evidence about replacing this

minimal antenatal care with remote assessment. If a woman attends an antenatal appointment but

describes respiratory symptoms, she should be advised to return home immediately. A member of clinical

staff should then make contact with the woman to risk assess whether an urgent home antenatal

appointment is required, or whether the scheduled appointment can be delayed for a period of 7 or 14

days.24

Clinics can be run effectively using telephone or video consultations instead of face to face

encounters. Remote appointments will be appropriate for a range of consultations, including:

• Some routine or specialist antenatal and postnatal appointments

• Supporting women at risk of or currently experiencing mental health problems

• Maintaining contact with families living with a range of vulnerabilities or where there are

safeguarding concerns

• Discussion of plans for birth

• Provision of breastfeeding support and early parenting advice and guidance

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Postnatal care should be individualized according to the woman and newborn’s needs.24

• The minimum recommended number of contacts is three: at day 1, day 5 and day 10.

• Maternity services should offer a combination of face-to-face and remote postnatal follow-up,

according to the woman and baby’s needs. Prioritize face-to-face visiting for women with:

• Known psycho-social vulnerabilities

• Operative birth

• Premature/low birthweight baby

• Other medical or neonatal complexities

Care for the Elderly

For COVID-19, those over the age of 60 could have a much higher fatality rate than the average

2.3%, with a study in China showing up to 15% in those over 80 years of age. Therefore, enhanced

precaution among older people and early preparation in long-term care facilities are important measures

to protect the elderly and vulnerable populations. Special attention should be paid to older adults with

chronic diseases as their prognosis is more likely to be worse. Older persons are advised to stay at home

unless necessary. Telemedicine is highly recommended and face-to-face consultation should be

minimized. When necessary, home visitation may be done provided proper PPE is used and infection

control is observed during visit.25

Communicable Diseases

Services rendered for non-COVID communicable diseases such as Tuberculosis and HIV should be

continued and proper referral to DOH centers should be facilitated.25

Non- Communicable diseases

All patients with chronic diseases such as hypertension, diabetes, thyroid diseases and other

metabolic disorders should be taken cared of with regular monitoring and follow up. For those who had

stroke and needs rehabilitation, proper referral should be coordinated with a Rehab Med specialist in the

nearest center.25

Mental Health

Counseling services for patients with depression and anxiety should be continued. They shall be

referred to a psychologist or psychiatrist as deemed necessary. These patients may also be offered online

guidance and resource centers.25

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Statement 10. A patient who consulted and whose symptoms were resolved may choose not come back

for follow-up. Patients with chronic diseases may be followed-up at longer intervals if their illness is

stable.

Family physicians are encouraged to reduce or postpone non-urgent face-to-face care, elective

procedures, and surgeries, are dependent on each practice’s geography, current and projected COVID-19

cases in the region, available personal protective equipment, and resources to conduct visits virtually

through telehealth or e-visits. Minimize the number of physicians, providers, and patients in clinic.21

Statement 11. Referrals for further assessment, diagnostic tests, or other procedures not available in the

clinic must first be coordinated with the referral center/site.

As much as possible, in the case of suspected COVID19 cases, transportation to a referral/transfer

site should be handled by a previously exposed family member. Majority of patients with CoVID-19 have

mild to moderate symptoms that do not necessitate confinement to tertiary hospitals, but there is a need

of these patients to be isolated in a facility to minimize spread of the disease. Family physicians are

encouraged to establish referral and partnership with the LGU. They have established roles and function in

the community where a family physician clinic is located. Family physicians should be aware about these

roles:26

• All Municipal and City Health Offices are directed to triage and manage all patients suspected to

have COVID-19 according guidelines, and coordinate with their respective Barangay Emergency

Health Response Teams for monitoring those requiring home quarantine

• If the LGU is capable of having a COVID facility for mild to moderate cases, this must be identified

following the mandated structural & manpower guidelines of the DOH.

• If the LGU is not capable of having one, it should coordinate with a nearby COVID center for its

confirmed cases.

The family physician should also know about the role of hospitals as referral for COVID-19.

• All Level 2 and 3 hospitals are directed to attend to all patients suspected of having COVID-19 and

those confirmed COVID-19 with mild symptoms.

• They should know their capacity to handle COVID – 19 patients.

• They should have an identified area with trained staff for such patients who needs hospital care.

• The hospital must refer patients who start to show signs of deterioration of symptoms by:

o Calling the nearest designated COVID referral hospital for availability of bed OR do online

referral if available.

o Providing transportation for the patient’s transfer

o Letting one to two staff accompany the patient during transfer

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Recommendation for Dissemination and Implementation

The recommendations will be forwarded to the PAFP Task Force on COViD-19. The Task Force will

disseminate to PAFP chapters and members in form of letters and circulars via email. Online webinars may

also be conducted to further inform the members.

Family Physicians are encouraged to use this as guide when they decide to resume clinic when the

ECQ is lifted and the general community quarantine is implemented.

References 1. Walton et al Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated

healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care. 2020 Apr

28:2048872620922795.

2. Tan et al Psychological Impact of Covid 19 pandemic among Health Care Workers in Singapore.

https://annals.org/aim/fullarticle/2764356/psychological-impact-covid-19-pandemic-health-care-

workers-singapore

3. Lai J et al. Factors associated with mental health outcomes among health care workers exposed to

coronavirus disease 2019. JAMA Netw Open 2020 Mar 23; 3:e203976.

(https://doi.org/10.1001/jamanetworkopen.2020.3976)

4. Zhang C, Yang L, Liu S, et al. Survey of Insomnia and Related Social Psychological Factors Among

Medical Staff Involved in the 2019 Novel Coronavirus Disease Outbreak. Front Psychiatry. 2020 Apr

14;11:306. American Medical Association Telehealth Implementation Playbook 2020

5. Gilmartin AA, Ralston KS, Petri WA Jr. Inhibition of Amebic Lysosomal Acidification Blocks Amebic

Trogocytosis and Cell Killing. mBio. 2017;8(4):e01187-17. Published 2017 Aug 29.

doi:10.1128/mBio.01187-17.

6. Centers for Disease Control. Return to Work (https://www.cdc.gov/coronavirus/2019-

ncov/hcp/return-to-work.html. Accessed April 2020)

7. PSMID. Unified Algorithms: Section 4 Guidelines on Return to Work.

(https://www.psmid.org/unified-covid-19-algorithms-4/. Accessed May 23, 2020.)

8. DOH AO 2020-0016. Minimum Health System Capacity Standards for COVID-19 Preparedness and

Response Strategies.

9. Shi Y, Wang J, Yang Y, et al. Knowledge and attitudes of medical staff in Chinese psychiatric

hospitals regarding COVID-19. Brain Behav Immun Health. 2020 Apr;4:100064.

10. NHS Guidance and standard operating procedures General practice in the context of coronavirus

(COVID-19), Publications approval reference: 001559, April 2020, Version 2.1.

11. DOH. COVID 19 Interim Guidelines. https://www.doh.gov.ph/sites/default/files/health-

update/jao2020-0001_0.pdf. Accessed May 23, 2020)

12. Finset A, Bosworth H, Butow P, Gulbrandsen P, Hulsman RL, Pieterse AH, Street R, Tschoetschel R,

van Weert J. Effective health communication - a key factor in fighting the COVID-19 pandemic.

Patient Educ Couns. 2020 May;103(5):873-876.

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13. Centers for Disease Control (2007). Guidelines for Isolation Precautions: Preventing Transmission

of Infectious Agents in Healthcare Settings.

(https://www.cdc.gov/infectioncontrol/guidelines/isolation/. Accessed April 2020)

14. Centers for Disease Control. Components of a Protective Environment

(https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/environment.html.

Accessed April 2020)

15. Centers for Disease Control. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities

(2008) https://www.cdc.gov/infectioncontrol/guidelines/disinfection/disinfection-

methods/miscellaneous.html. Accessed May 2020)

16. CDC. Strategies to Optimize the Supply of PPE and Equipment.

(https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Accessed May 2020)

17. DOH. COVID-19 Interim Guidelines. https://www.doh.gov.ph/sites/default/files/health-

update/dm2020-0157.pdf. Accessed May 2020)

18. Department of Health - National Privacy Commission (DOH- NPC) Joint Memorandum Circular No.

2020-0001 “Guidelines on the Use of Telemedicine in COVID-19 Response”

(https://www.doh.gov.ph/sites/default/files/health-update/mc2020-0016.pdf. Accessed May

2020)

19. American Medical Association Telehealth Implementation Playbook 2020. (https://www.ama-

assn.org/system/files/2020-04/ama-telehealth-playbook.pdf. Accessed May 2020)

20. WHO Covid 19 Operational Guidance for Maintaining Essential Health Services During an

Outbreak, March 25, 2020 (https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/technical-guidance/maintaining-essential-health-services-and-systems.

21. American Academy of Family Physicians. Covid 19: Guidelines for Family Physicians on Preventive

and Non-urgent Care. Apr 15, 2020. AAFP.

22. WHO Europe. Guidance on routine immunization services during COVID-19 pandemic in the WHO

European Region. March 20,2020.

23. American Academy of Pediatrics. Pediatric Practice Management Tips During the COVID-19

Pandemic. (https://services.aap.org/en/pages/2019-novel-coronavirus-COVID-19-

infections/pediatric-practice-management-tips-during/. Accessed May 2020)

24. RCOG. Guidance for antenatal and postnatal services in the evolving coronavirus (COVID-19)

pandemic (https://www.rcog.org.uk/globalassets/documents/guidelines/2020-05-22-guidance-

for-antenatal-and-postnatal-services-in-the-evolving-coronavirus-covid-19-pandemic.pdf.

Accessed May 23, 2020)

25. WHO Covid 19 Operational Guidance for Maintaining Essential Health Services During an

Outbreak, March 25, 2020 (https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/technical-guidance/maintaining-essential-health-services-and-systems. Accessed March 25,

2020)

26. DOH. COVID-19 Interim Guidelines. (https://www.doh.gov.ph/sites/default/files/health-

update/jao2020-0001_0.pdf. Accessed May 2020)