Pan American Health Organization · 2020
Algorithm for early case identification, severity-based triage, and management of COVID-19 patients in primary care and remote settings.
- Issuer
- Pan American Health Organization
- Edition
- 2020
- Audience
- Primary care clinicians, healthcare workers in remote settings
- Evidence
- Expert consensus based on evidence review
- Reviewed
- 20 Oct 2026 · GMJ
What this guideline says
GMJ summary
This flowchart provides a systematic approach to managing suspected COVID-19 patients at the first level of care and in remote areas of the Americas. It focuses on early case identification based on severity, risk stratification, and timely referral decisions. The algorithm guides clinicians through initial assessment, severity classification (mild, moderate, severe, critical), and appropriate management including isolation decisions, oxygen support, pharmacological interventions, and criteria for referral to higher levels of care.
The document stratifies patients according to risk factors (including age over 60, cardiovascular disease, diabetes, obesity, hypertension, immunodeficiency) and clinical severity markers (oxygen saturation, respiratory rate, emergency signs). It provides specific thresholds for intervention: SpO₂ <94% triggers detailed evaluation, SpO₂ <90% indicates need for oxygen support and possible transfer, and persistent hypoxia despite oxygen requires urgent referral to mechanical ventilation facilities.
Management recommendations include conservative use of acetaminophen (500 mg every 6–8 hours, maximum 4 g/day), thromboprophylaxis with enoxaparin 40 mg daily for at-risk patients, stepwise oxygen therapy protocols with specific FiO₂ estimates, awake prone positioning, and conservative fluid administration. The guideline explicitly advises against routine antibiotic use unless bacterial infection is suspected and provides detailed criteria for recognising deterioration requiring escalation of care.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Perform urgent evaluation if SpO₂ <94%, respiratory rate >20 in adults, or emergency signs (difficulty breathing, persistent chest pressure, confusion, cyanosis) are present
- Isolate patients at home (mild, no risk factors), in designated facilities (mild with risk factors), or in health facilities (moderate/severe) based on risk stratification
- Administer acetaminophen 500 mg every 6–8 hours (maximum 4 g per day) for fever or pain; avoid antibiotics unless bacterial infection is suspected
- Initiate thromboprophylaxis with enoxaparin 40 mg daily for patients with risk factors for thromboembolism (respiratory rate >20, elevated C-reactive protein, D-dimer, fibrinogen)
- Start oxygen at 5 L/min via nasal cannula with awake prone positioning for SpO₂ <90%; escalate to 6–10 L/min with mask, then 10–15 L/min with reservoir bag if no improvement
- Estimate FiO₂ by flow rate: 2–4 L/min = 0.28–0.36; 5 L/min = 0.40; 6–10 L/min = 0.44–0.60; 10–15 L/min = 0.60–0.95
- Refer to second level of care if SpO₂ remains <90% despite oxygen, or if deterioration signs develop (increased dyspnoea, hypotension, confusion, persistent chest pain, limb inflammation)
- Severe pneumonia is defined as respiratory rate >30 breaths/min, severe respiratory distress, or SpO₂ <90% on room air in adults
COVID-19 Disease Severity Classification
Table extracted from the guideline
| Severity | Definition |
|---|---|
| Mild disease | Symptomatic patients meeting case definition without evidence of viral pneumonia or hypoxia |
| Moderate disease (pneumonia) | Adults: fever, cough, dyspnoea, fast breathing but no severe pneumonia signs; SpO₂ ≥90% on room air. Children: cough/difficulty breathing + fast breathing and/or chest indrawing; no severe pneumonia signs |
| Moderate disease (severe pneumonia) | Adults: pneumonia signs plus respiratory rate >30/min, severe respiratory distress, or SpO₂ <90% on room air. Children: pneumonia signs plus central cyanosis, SpO₂ <90%, severe respiratory distress, inability to feed, lethargy, unconsciousness, or convulsions |
| Critical disease (ARDS) | Bilateral opacities on imaging within 1 week of onset; respiratory failure not explained by cardiac failure. Mild: 200 mmHg < PaO₂/FiO₂ ≤300 mmHg; Moderate: 100 mmHg < PaO₂/FiO₂ ≤200 mmHg; Severe: PaO₂/FiO₂ ≤100 mmHg (all with PEEP ≥5 cmH₂O) |
| Critical disease (sepsis) | Adults: life-threatening organ dysfunction from dysregulated host response to infection. Children: suspected/proven infection and ≥2 SIRS criteria including abnormal temperature or white blood cell count |
| Critical disease (septic shock) | Adults: persistent hypotension despite volume resuscitation requiring vasopressors (MAP ≥65 mmHg) and lactate >2 mmol/L. Children: hypotension or 2–3 of altered mental state, tachy/bradycardia, prolonged capillary refill, tachypnoea, mottled/cool skin, increased lactate, oliguria, hyper/hypothermia |
Source: Pan American Health Organization, Flowchart for the Management of Suspected COVID-19 Patients at the First Level of Care and in Remote Areas in the Region of the Americas. Reproduced in summary form.
From the guideline
Verbatim
“Do not administer antibiotics unless a bacterial infection is suspected.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked extensively on health system preparedness in the Caucasus, I recognise this flowchart addresses a critical gap we faced during the pandemic: standardised triage protocols for under-resourced primary care settings. The oxygen titration guidance—starting at 5 L/min and escalating systematically based on SpO₂ response—is exactly what our rural family medicine teams in mountainous regions needed when pulse oximeters became available. I would stress to Georgian colleagues the thromboprophylaxis recommendation of enoxaparin 40 mg daily for patients with respiratory rate above 20 or inflammatory markers elevation, as we saw significant thromboembolic complications in hospitalised patients. The practical caveat is that implementing this protocol requires reliable oxygen supply chains and functioning cold chains for enoxaparin in remote areas—infrastructure gaps that persisted in some regions even during peak pandemic response, and which national preparedness plans must address before the next respiratory disease emergency.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 20 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is directly applicable to Georgia and the South Caucasus region, where first-level primary care facilities and remote mountainous areas face similar resource constraints as other middle-income settings in the Americas. Georgian national COVID-19 protocols would need to integrate these triage algorithms with local laboratory capacity (C-reactive protein, D-dimer availability varies by facility), oxygen supply infrastructure (particularly in rural Racha, Svaneti, Tusheti regions), and telemedicine networks established during the pandemic. The risk factor profile (high prevalence of cardiovascular disease, diabetes, hypertension in Georgia) makes the stratification approach particularly relevant. Implementation would require adaptation of referral pathways to Georgia’s three-tier health system, ensuring rural ambulatori and local polyclinics can access specialist consultation and timely transfer to regional or republican hospitals with mechanical ventilation capacity.
Questions this guideline answers
Quick answers
When should I start oxygen therapy for a COVID-19 patient?
Start oxygen at 5 L/min via nasal cannula if SpO₂ falls below 90%. Use awake prone positioning and clear secretions. If SpO₂ remains <90% or respiratory distress increases, escalate to oxygen mask at 6–10 L/min, then mask with reservoir bag at 10–15 L/min if needed.
Which COVID-19 patients require thromboprophylaxis?
Consider enoxaparin 40 mg daily for patients with risk factors for thromboembolism, including respiratory rate over 20 breaths/min or elevated levels of C-reactive protein, D-dimer, or fibrinogen.
What are the criteria for referring a patient to a higher level of care?
Refer if SpO₂ remains below 90% despite oxygen therapy, or if deterioration signs develop: increased difficulty breathing, drop in blood pressure, confusion, persistent chest pain, cyanosis, limb inflammation, dizziness, loss of consciousness, or respiratory rate over 24 breaths/min with emergency signs.
Should I prescribe antibiotics for all suspected COVID-19 patients?
No. Do not administer antibiotics unless a bacterial infection is specifically suspected based on clinical evaluation and available laboratory tests. COVID-19 is a viral infection and does not require routine antibiotic therapy.
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Quality & accreditation
Other guidelines on this topic
- Technical recommendations for configuration of a triage area for patients with respiratory symptoms
- Ongoing Living Update of Potential COVID-19 Therapeutics: Summary of Rapid Systematic Reviews
- Ongoing Living Update of Potential COVID-19 Therapeutics: Summary of Rapid Systematic Reviews
- Considerations for the Implementation and Management of Contact Tracing for Coronavirus Disease 2019 (COVID-19) in the Region of the Americas
- Ethics guidance for the use of scarce resources in the delivery of critical health care during the COVID-19 pandemic
- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Status
- Current
- Published
- 2020-01-01
- Scope
- First level of care and remote areas
- Audience
- Primary care clinicians, healthcare workers in remote settings
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus based on evidence review
- Record history
- Created 20 Oct 2026 · updated 20 Oct 2026 · next check Apr 2027
Pan American Health Organization. Flowchart for the management of suspected COVID-19 patients at the first level of care and in remote areas in the Region of the Americas, July 2020. Washington, D.C.: PAHO; 2020. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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