COVID-19 Clinical Pathway

“This clinical path is a general guideline to assist in the management of patients. This guideline is not designed to replace clinical judgment or individual
patient needs.”

Admission Date: Time: Admitted From: ECC  ACC  Transfer 

No Code  /Date: Age: M  F  Consultant: Department:

ESSENTIAL INFORMATION FOR COVID-19 ADMISSIONS

 Diagnosis of COVID-19 confirmed (Positive Covid-19 PCR) Yes  No 

 Diagnosis of Covid-19 highly probable (Any of the criteria below) Yes  No 

Epidemiological Criteria Clinical Criteria Laboratory Criteria Radiological Criteria

 Contact with a
confirmed case of
Covid-19.
 Contact with a patient
with Covid-19 classic
symptoms or return of
contact from a high-
transmission zone but
has negative or
undetermined Covid-19
PCR.
 Adult with severe acute  Absolute lymphocyte  COVID19 - Interstitial
respiratory illness (ICU count < 0.8 changes on portable Chest
admission, ARDS or CURB  N:L ratio > 3 X-ray and negative Covid-19
65 score ≥3 points)  Platelets < 100 PCR and any of the previous
 CRP > 100 criteria.
PLUS  LDH > 245 U/L
 D-dimer > 1000 ng/mL
 Clinical assessment that  CPK > twice upper limit
patient is not improving and of normal
no clear underlying causes.  Elevated troponin
 Ferritin > 300 ug/L

 Assessment of Severity: Indications for Hospital Admission and Site of Care

(History, Physical Examination, Investigations)
PR……. RR…..…BP…..…… Temp..…….Pulse Oximetry…........ On RA CURB-65 Score:….

Community-Acquired Pneumonia: Presence of any of the Following Features makes Hospital Admission
Obligatory

Site of General Ward Intensive Care Unit

Care

 Age >60 yr WBC < 4000/mm3 Indicated in the Presence of any of the
 Persistent vomiting 
Or > 30,000/mm3 Following
 Significant co-morbid 
or Neutrophils <1,000/mm3  PaO2/FIO2 <250
condition or recent 
Hb < 90 gm/L  BP <90/60
hospitalization 
Cr > 1.2 mg/dL
 Social exclusion 
PaO2 < 60 mmHg Additional Indications:
 Impaired level of 
PaCO2 > 50 mmHg  Coma
consciousness 
PH < 7.35  Hemodynamic Compromise
 Cyanosis 
Abnormal Coagulation  Need for mechanical ventilation
 Temp <35°C or >40°C 
CXR: Multilobar  CURB-65 Score: 3 or more
 PR 125 per minute
 RR > 30 per minute
 Atrial fibrillation
 Please Tick as appropriate: Risk Factors for Severe COVID-19 Disease

Epidemiological Factors Vital Signs Laboratory Parameters

 Age > 55  Respiratory rate > 30  D-dimer > 1000 ng/mL

 Pre-existing pulmonary disease breaths/min  CPK > twice upper limit of normal
 Chronic kidney  Heart rate > 125  CRP > 100
 Diabetes with A1c > 7.6% beats/min disease  LDH > 245 U/L
 History of hypertension SpO2 < 90% on  Elevated troponin
 History of cardiovascular disease ambient air  Admission absolute lymphocyte count
 History of transplant or other < 0.8
immunosuppression  Ferritin > 300 ug/L
 All patients with HIV (regardless  N:L ratio > 3
of CD4 count)  Platelets < 100

Please Tick as appropriate: COVID-19 Clinical Syndrome Recommendations

Uncomplicated URTI: patient with non-specific symptoms such SpO2 >90%, no risk factors for
as fever, fatigue, cough (with or without sputum production), severe disease:
anorexia, malaise, muscle pain, sore throat, nasal congestion,
 Mild illness or headache.
Atypical symptoms/No Pneumonia or LRTI: Patients may also
present with diarrhea, nausea, and vomiting. (elderly,
immunocompromised, pregnant …)
  Supportive care
 No specific antiviral
 Avoid NSAID if
possible
 Home isolation with
close monitoring

SpO2 >90%, plus risk factors

for severe disease:
Above PLUS consider starting
hydroxychloroquine (Check
ECG for QTc Prolongation)

Adult with pneumonia but no signs of severe pneumonia and Infectious disease Consult
 Pneumonia
no need for supplemental oxygen. Check ECG for QTc
Prolongation
Hydroxychloroquine (400 mg
BID x2 followed by 400 mg
daily (200 mg BID) while
hospitalized, up to 5 days).
OR
Fever or suspected respiratory infection, plus one of the Lopinavir/ritonavir 200/50
 Severe following: respiratory rate > 30 breaths/min; severe respiratory (LPV/R or Kaletra) 2 Tab BID
pneumonia distress; or SpO2 ≤ 93% on room air (< 87 % on room air if for 7 days for certain moderate
chronic lung disease/chronic respiratory failure) and severe presentations
(Monitor LFT)

Onset: within 1 week of a known clinical insult or new or

worsening respiratory symptoms.

Chest imaging (radiograph, CT scan, or lung ultrasound):

 Acute
bilateral opacities, not fully explained by volume overload,
respiratory
lobar or lung collapse, or nodules.
distress
syndrome
Oxygenation impairment in adults:
Mild ARDS: PaO2/FiO2a ≤ 300 mmHg
Moderate ARDS: PaO2/FiO2 ≤ 200 mmHg
Severe ARDS: PaO2/FiO2 ≤ 100
Presenting Symptoms: Choice of antibiotic:
1. Patients with Pneumonia
on CXR or HRCT (Ward
HPI: Admission): Start Ceftriaxone
+ Oral Azithromycin.

2. Underlying lung disease

e.g. Bronchiectasis: consider
antipseudomonal antibiotic in-
stead of Ceftriaxone plus the
other antibiotics.

3. Suspected aspiration:
2nd or 3rd generation
cephalosporin and
PH Clindamycin or Metronidazole
Previous Hospital Adm: Y  N  DM: Y N  B Asthma/COPD: Y  N  plus the other antibiotics.
Hypertension: Y  N  Heart Failure: Y  N  Immunodeficiency: Y  N  Cancer: Y  N 
Other:………………….. 4. Influenza superinfection
(rare) Use Anti-staphylococcal
Nutritional/Functional Hx: Diet: N  DM  Low Salt  Other: antibiotic.

Functional Hx: ADLN  Restricted  5. ICU admission:

Piperacillin/Tazobacatm +
Oral Azithromycin.
Immunization Hx: Unknown  Current:
If concern for MRSA: Add
SH/FH Vancomycin or Linezolid.
Marital status: S  M  D  W  Smoking: Y  N  Ex:  Pack Years:……..
TB contact Y  N  Animal contact Y  N  Bird contact Y  N  6. In patients with positive
Recent travel Y  N  Country……….. HIV Risk: Y  N  COVID-19 PCR test consider
DH: starting the after
Recent antibiotic & Which: Infectious Disease
Consultation:
AH:
Penicillin Allergy: Y  N  Hydroxychloroquine/
_______________________________________________________________ Chloroquine.
Physical Examination:
General: Or
CVS Lopinavir/Ritonavir
Chest Avoid steroids unless for
Abdomen another indication.

CNS

Summary of Case:

Plan of Action:
Educational Needs/Discharge Planning:
Disease:  Medications:  Treatment Plan:  Pain Management: 
Nutrition:  Equipment:  Other: 
Name & Signature:
Senior Physician Comments:
Concur with above findings: Y  N  Expected length of stay:
Revisions/Additions:
 COVID-19 ADMISSION ORDERS

Date and Time:

Inform Infection Control Team
Condition: Stable  Unstable 
Vital signs: Q Hourly
Insert Canula
Allergies:
Diet:
Activity: Mobilize the patient, if tolerated: sit out for 20 minutes.
Gluco checks: Q ………..Hrly
Keep O2 saturation >/= -------------%
Consult Infectious Disease, Pulmonary and ICU as appropriate.
Other

Investigations/Results
Covid-19 PCR (Throat, Nasopharyngeal or Sputum-Repeat as appropriate)
Chest x-ray:
HRCT Chest (order if Covid-19 PCR is negative and diagnosis is highly-probable:
ABG on RA/Oxygen: pH PaO2 PaCO2 HCO3 -
CBC/Diff: Hb MCV TWBC Neut Lymp Platelets Eosinophils
Renal: Urea Creat Na+ K+ Glucose HCO3- Cl- Ca++ Mg++
CPK (marker of severity/cardiac injury)
LDH (marker of severity)
Ferritin (marker of severity)
d-Dimer (marker of severity)
LFT
INR (usually increased in Covid-19)
ECG (Age > 40 yrs, irregular pulse etc.):
Sputum Gram stain and C/S:
Sputum for AFB x 3
Blood C/S
Urinalysis:
CRP (Usually high in Covid-19)
Procalcitonin (Usually negative/low in Covid-19 unless with secondary bacterial infection)
Other tests

Medications
Ceftriaxone 1-2gm q 24 hrly
Azithromycin 500 mg PO Stat then 250 mg PO q 24 hrs for 4 days.
(monitor QTc if Chloroquine/Hydroxychloroquine is added)
Piperacillin/Tazobacatm 4.5 g IV every 6 hours
Lopinavir/ Ritovanir 400/100 every 12 hours for 7 days
Hydroxychloroquine 400 mg or Chloroquine 500 mg every 12 hours
Oxygen (Delivery device & percent):
IV Fluid (Specify type & rate):
VTE prophylaxis if indicated:
■ Heparin 5000 Unit SubQ q 12 hrly ■ Heparin 5000 Unit SubQ q 8 hrly
■ Elastic stockings ■ Enoxaparin 40 mg SubQ q 24 hrly
Other Orders:
 COVID-19 DISCHARGE ORDERS

Physician Name & Signature/Date:________________________________________________

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Physician Name & Signature/Date:________________________________________________