Pan American Health Organization · Version 1.0, March 2020
Technical guidance for health systems to reorganize and expand hospital and primary care capacity during the COVID-19 pandemic through surge planning, bed management, and service integration.
- Issuer
- Pan American Health Organization
- Edition
- Version 1.0, March 2020
- Audience
- Hospital administrators, health system managers, ministries of health, emergency operations centers, primary care network coordinators
- Evidence
- Expert consensus based on early COVID-19 experience from China and Italy, existing WHO and PAHO emergency response frameworks
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This technical working document provides comprehensive recommendations for health systems to reorganize and progressively expand services in response to COVID-19. It addresses the critical challenge of preventing health service collapse through strategic planning across first-level care, hospital services, and emergency medical services. The document emphasizes that saving lives depends not only on increasing bed capacity but on coordinated actions including early case detection, patient monitoring at home, infection control, and maintaining services for patients with other conditions.
The guidance presents 10 key measures: strengthening first-level care response capacity; establishing centralized bed management mechanisms; implementing separate flows for COVID-19 patients; converting beds by clinical complexity (Types A-D); strengthening home care and telehealth; coordinating prehospital services; clinical management networking; reorganizing and training health workers; and guaranteeing supply management. Central to the approach is the concept of ‘flattening the curve’ through coordinated nonpharmacological interventions combined with health service adaptation.
The document provides detailed operational guidance including staffing ratios (e.g., one intensive care physician per 6 Type A beds with 2 nurses and 3-4 nursing assistants), bed conversion protocols, and supply management strategies including maintaining 6 months of stock at central level, 3 months at intermediate level, and 2 months at service level.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Classify hospital beds by four complexity levels: Type A (critical care, 1 intensivist per 6 beds with 2 nurses), Type B (intermediate critical care, 1 intensivist per 6 beds), Type C (intermediate care, 1 specialist per 12 beds with 1 nurse), Type D (basic care, 1 physician per 18 beds)
- Establish centralized bed management units to maintain daily inventory of all beds, especially intermediate and critical care capacity, coordinating admissions and transfers to prevent patient 'roving'
- Reorganize first-level care facilities into triage centers with extended hours, specimen collection capacity, and coordination with hospital bed managers or emergency services (911)
- Implement separate patient flows: dedicated emergency rooms for respiratory symptoms, isolated waiting areas, clearly marked routes, and cohort isolation when epidemiologically required
- Strengthen home hospitalization using telehealth platforms (Skype, Webex, WhatsApp) for monitoring 40%-80% of mild-to-moderate COVID-19 cases, freeing hospital beds for severe cases
- Maintain minimum supply stocks: 6 months at central warehouses, 3 months at regional level, 2 months at facility level; conduct inventories twice monthly to adjust distribution
- Discharge criteria: clinically stable patients, limited parenteral drug requirements, transferable to lower-complexity facilities; do NOT discharge chronic disease patients (hemodialysis), high-risk pregnancies, or emergency admissions
- Pre-triage vital sign thresholds: normal oxygen saturation >95% (abnormal <93%), normal respiratory rate 12-16/minute (abnormal >30), refer patients with respiratory system changes for hospital triage
Types of beds by complexity (Table 2)
Table extracted from the guideline
| Type | Patient condition | Medical personnel | Ratio | Key technology |
|---|---|---|---|---|
| A (Critical) | Unstable critical condition | Intensive care physician, intensive care nurse | 1 physician + 2 nurses + 3-4 assistants per 6 beds | Mechanical ventilators, invasive monitoring, portable X-ray, infusion pumps |
| B (Intermediate critical) | Unstable non-critical requiring constant monitoring | Intensive care physician, intensive care nurse | 1 physician + 2 nurses + 3-4 assistants per 6 beds | Mechanical ventilators, non-invasive monitoring, crash cart, infusion pumps |
| C (Intermediate) | Stable condition | Specialist (internist, emergency, infectious disease), professional nurse | 1 physician + 1 nurse + 3-4 assistants per 12 beds | Non-invasive monitoring, oxygen therapy, crash cart |
| D (Basic) | Stable condition | General practitioner, specialized nurse | 1 physician + 1 nurse + 3-4 assistants per 18 beds | Oxygen access, saturation measurement, crash cart with defibrillator |
Source: Pan American Health Organization, Reorganization and Progressive Expansion of Health Services for the Response to the COVID-19 Pandemic. Reproduced in summary form.
From the guideline
Verbatim
“The main objective of health services in the response to COVID-19 is to Save Lives, a country's capacity to respond to the pandemic will depend on multiple factors that affect the spreading of the virus in the population.”
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 Chair of Georgia's Public Health Institute and having worked with WHO on health system strengthening, I recognize this document addresses the central challenge our region faced in 2020 and will face in future pandemics: preventing health service collapse through coordinated reorganization rather than simply adding beds. The recommendation I would stress to Georgian colleagues is establishing a functional centralized bed management unit with daily reporting from all sectors—public, University Clinics, private hospitals, and the insurance system—because our fragmented landscape makes 'roving patients' a real risk that wastes critical time and ambulance resources. The guidance on converting intermediate care beds (Type C) by adding trained staff and mechanical ventilators is more realistic for Georgia than rapidly expanding intensive care units, given our medical workforce distribution. One implementation caveat is that the recommended supply stocks (6 months central, 3 months regional, 2 months facility) require significant upfront investment and warehouse capacity that will compete with other health priorities; countries must model the cost-benefit against the risk of supply chain disruption based on their import dependencies and regional cooperation agreements.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
This guidance is directly relevant for Georgia and South Caucasus countries facing COVID-19 or preparing for future pandemic surges. Georgia’s mixed health system—with public, private, and social insurance sectors—makes the recommendation for functional integration and centralized bed management particularly important. The emphasis on strengthening primary care networks aligns with Georgia’s ongoing primary healthcare reforms under the Universal Healthcare Programme. Countries in the region should adapt the bed classification system to local hospital configurations, establish national bed management information systems (the document offers a free PAHO tool), and ensure adequate PPE supply chains given potential import dependencies. The telehealth recommendations are feasible given improving internet infrastructure in urban Georgia, Armenia, and Azerbaijan, though rural connectivity remains a constraint requiring telephone-based alternatives.
Questions this guideline answers
Quick answers
How should hospital beds be reorganized during a COVID-19 surge?
Convert beds to four complexity levels (A-D) based on patient acuity and nursing requirements. Reduce basic Type D beds, moving patients to home care or pre-discharge facilities. Expand Type C intermediate beds for COVID-19 patients requiring oxygen and monitoring. Reserve Type A/B critical beds for shortest stays, ensuring patients can move between levels. Suspend elective procedures and convert non-essential departments (endoscopy, post-anesthesia units) to patient care areas.
What staffing ratios are recommended for different bed types?
Type A (critical care): 1 intensivist + 2 intensive care nurses + 3-4 nursing assistants per 6 beds, permanently assigned. Type B (intermediate critical): same ratio as Type A. Type C (intermediate): 1 specialist + 1 nurse + 3-4 assistants per 12 beds. Type D (basic): 1 general practitioner + 1 nurse + 3-4 assistants per 18 beds. Use cohort methodology, assigning staff groups to specific patient areas (COVID-positive, pending results, negative).
How can first-level care be strengthened for pandemic response?
Strengthen basic health teams with medical/nursing personnel, community health workers, and logistical tools for call center services, epidemiological surveillance, monitoring at-risk groups, and chronic disease management. Convert selected first-level facilities into triage centers with extended hours, specimen collection, emergency services, and ambulance coordination. Equip centers with specialists (emergency physicians, internists, family doctors), telehealth capacity (Skype, Webex, WhatsApp), and enhanced infection control measures.
What supply management strategies ensure continuity during surges?
Maintain minimum stocks: 6 months at central warehouses, 3 months at intermediate (regional) level, 2 months at service facilities. Conduct inventories at least twice monthly to monitor consumption versus estimates. Identify critical products at risk of stockouts (<3 months inventory). Use 'push distribution' (central calculation) when inventory systems are deficient. Establish satellite pharmacies in COVID-19 units with defined protocol-based stocks. Create emergency procurement committees with regulatory fast-track for essential goods not marketed domestically.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- Version 1.0, March 2020
- Status
- Current
- Published
- 2020-01-01
- Languages
- English, Spanish
- Scope
- Health system reorganization and surge capacity planning for COVID-19 pandemic response
- Audience
- Hospital administrators, health system managers, ministries of health, emergency operations centers, primary care network coordinators
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus based on early COVID-19 experience from China and Italy, existing WHO and PAHO emergency response frameworks
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Reorganization and Progressive Expansion of Health Services for the Response to the COVID-19 Pandemic. Technical Working Document, 27 March 2020. Washington, D.C.: PAHO; 2020. (PAHO/HSS/HS/COVID-19/20-0018).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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