Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

AUG 312071

ADMINISTRATIVE ORDER
No. 2021 -_Q042

SUBJECT: Guidelines for COVID-19 Surge Response of Health Facilities

I. RATIONALE
The advent of COVID-19 variants such as the Alpha and Delta variants which have higher
transmissibility rates poses a huge risk to the health system. There is a need for an automatic
escalation and de-escalation of COVID-19 response in Centers for Health Development, Local
Government Units, and health facilities.
A surge means that the local health system is overwhelmed and immediate actions are
required to meet the continuous increase in demand that may exceed normal capacity. Lessons
from previous surges have emphasized the need for health facilities and local implementers to
prepare beforehand and quickly respond in the event of an actual surge in COVID-19 cases. A
three-stage response plan, namely, the Preparedness Stage, Response Stage, and the Surge
Response Stage with well-defined triggers is
introduced to facilitate a harmonized response the
health facility level and at the community level. Action plans recommended in this policy includes
at
an automatic and flexible type of bed capacity during a surge, in which a hospital shifts focus its
to COVID-19 thereby increasing its COVID-19 dedicated beds in a step-by-step manner,
depending on the needs of the situation.

II. OBJECTIVES
A. General Objective
Define indicators and specific strategies for health facilities, local implementers, and
Centers for Health Development to
guide their continuous COVID-19 response.

B. Specific Objectives
1. Identify critical indicators and thresholds to efficiently monitor health facilities;
2. Set corresponding strategies and action points for local implementers and health
facilities; and
3. Guide health facilities when to escalate and de-escalate COVID-19 response
including when to increase or decrease dedicated COVID-19 hospital and ICU
beds.

Building I, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ® Trunk Linc 651-7800 local fos, TIL, 1112, 1113
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 11. SCOPE OF APPLICATION
This Order shall apply to DOH Central Office bureaus, units and attached agencies, DOH
Centers for Health Development, DOH Hospitals, including the Bangsamoro Autonomous
Region of Muslim Mindanao subject to the applicable provisions of RA 11054 or the
“Bangsamoro Organic Act” and subsequent rules and policies issued by the Bangsamoro
government, Local Government Units (LGUs), all public and private health facilities, and other
relevant stakeholders involved in the COVID-19 response.

IV. GENERAL GUIDELINES

A. All CHDs, LGUs, and health facilities shall utilize the Alert Levels released by the
Inter-Agency Task Force for the Management of Emerging Infectious Diseases
(IATF-EID), in accordance with the Crisis Action Plan issued through [ATF
Resolution 131, in their planning and response for COVID-19.
The surge response shall be activated at two levels regardless of community
quarantine status: 1) CHD and LGU-level surge response, and 2) facility-level surge
response (Annex A).
The surge response shall focus on the following five (5) major areas:
1. Increasing COVID-19 dedicated beds including essential medicines, oxygen, and
other supplies;
Increasing ICU beds for COVID-19;
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Increasing TTMF beds and implementation of home care during surge;

Human Resources for Health (HRH) augmentation; and
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HRH support in the form of transportation, accommodation, etc.

All CHDs shall monitor province and city level indicators and shall guide the COVID-
19 response of all LGUs and health facilities in their provinces and/or region. This
includes monitoring oxygen supplies in the region and assisting both public and
private health facilities in planning for oxygen requirements as detailed in the
Department Memorandum (DM) No. 2021-0357, “Revised Contingency Plan to
Secure Enough Oxygen Supply in Hospitals During a COVID-19 Surge”.
The DOH, through the Epidemiology Bureau, shall communicate to CHDs and LGUs
areas with high Alert Levels to heighten their response.
All health facilities shall monitor facility level indicators and activate facility’s
contingency plans when indicated.
All hospitals shall admit patients based on the DM 2020-0512, “Revised Omnibus
Interim Guidelines on Prevention, Detection Isolation, Treatment, and Reintegration
Strategies for COVID-19” and its updates. Patients shall be isolated in the appropriate
health facility depending on the case severity and in consideration of their
comorbidities.
H. Primary Care Facilities, during a surge, shall endeavor to continue to provide health
services mainly through the use of telemedicine in accordance with the latest DOH
guidelines and standards.
I. As part of the contingency plans for oxygen supply, all hospitals shall secure their
stockpile of oxygen cylinders, among others. As a long term strategy, the DOH shall
endeavor to upgrade existing oxygen generating plants in the DOH Hospitals, and
build an oxygen generating plant in regions with no existing hospital oxygen plants.

SPECIFIC GUIDELINES
A. Three (3) Stages of Surge Response for Health Facilities
1. The Surge Response shall be organized into the following stages with well-defined
triggers:
a. Preparedness Stage - refers to the period in which there is no surge in the
area;
b. Response Stage - refers to the period right before there is a surge in the
facility or there is anticipated surge in the area (i.e. identified variant in the
area); and
c. Surge Response Stage - refers to the period in which there is a surge in the
health facility or community transmission in the area.

2. All CHDs, LGUs, and health facilities shall determine the stage of surge response
in their area or facility, and endeavor to follow the recommended action points
identified per stage.

B. COVID-19 CHD/LGU Surge Response for Health Facilities

I. All CHDs shall utilize the Alert Levels released by the IATF and determine the
response stage in their area every 2 weeks, and as necessary (see Annex A, Table
1.1).
2. All CHDs shall institute the necessary action points and guide LGUs and health
facilities in the COVID-19 response. The action points per stage presented in Table
1.2 shall serve as a guide to local implementers.

a. During the Preparedness Stage, CHDs and LGUs shall ensure that health
facilities have contingency plans in the 5 major areas. All health facilities
shall endeavor to utilize telemedicine as an alternative to face-to-face
consultations. At this stage, hospitals may utilize their previously
dedicated COVID-19 beds for non-COVID-19 cases, provided that the
hospital maintains their bed occupancy rates below 50%, provided further
that they are able to revert these beds into COVID-19 beds once thresholds
for the response stage have been reached.
b. During the Response Stage, CHDs shall strictly monitor at least 30%
COVID-19 dedicated beds in government hospitals and 20% for private
 hospitals. For Levels 2 and 3 hospitals, at least 15% of their total dedicated
beds should be ICU beds or ICU ready beds, which are converted regular
hospital beds that can cater to critical cases.
During the Surge Response Stage, CHDs shall strictly monitor a province-
wide increase of dedicated beds to at least 50% for government hospitals
and 30% for private hospitals. For Levels 2 and 3 hospitals, at least 30%
of their total dedicated beds should be ICU beds or ICU ready beds, which
are converted regular hospital beds that can cater to critical cases. At this
stage, HRH augmentation and support (e.g. transportation,
accommodation) shall be provided accordingly.
When 50% or more provinces in the region are at Alert Level 4 OR more
than 70% utilization of region’s ICU beds or hospital beds is reached,
CHDs shall issue a Regional Order instructing a region-wide increase of
dedicated beds to at least 50% for government hospitals and 30% for
private hospitals. For Levels 2 and 3 hospitals, at least 30% of their total
dedicated beds should be ICU beds or ICU ready beds.

C. COVID-19 Facility Surge Response

l. All hospitals shall weekly analyze facility level indicators and determine the
response stage in their facility (see Annex C, Table 2.1).
All hospitals shall endeavor to have an automatic escalation/ de-escalation or
progressive surge response that is able to allocate beds and re-assign human
resources depending on the stage of COVID-19 response.
All hospitals shall activate their surge plans depending on the stage. The action
points per stage presented in Table 2.2 shall serve as a guide to hospitals.
As part of the contingency plans detailed in DM No. 2021-0357, all hospitals shall
secure the needed oxygen supply for their facility through the following:
Preparation of a COVID-19 Surge Stockpile of oxygen cylinder tanks
depending on the Surge Response Stage:
i. Atthe Preparedness Stage (Alert Levels 1-2), the number of oxygen
cylinder tanks shall be equivalent to the maximum recorded oxygen
consumption, accounting for lead time and 10% buffer; and
ii. At the Response Stage (Alert Level 3), the number of oxygen
cylinder tanks shall be equivalent to 1.5 times the maximum
recorded oxygen consumption, accounting for lead time and 10%
buffer; and
iii. Atthe Surge Response Stage (Alert Level 4), the number of
oxygen
to
cylinder tanks shall be equivalent 2 times the maximum recorded
oxygen consumption, accounting for lead time and 10% buffer.

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 b. Strengthen coordination with existing oxygen private suppliers and

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refilling schedules to ramp up their capacity in the event of a surge. All
hospitals shall:
i. Establish a refilling schedule of oxygen cylinder tanks to maintain
the COVID-19 surge stockpile at any day and adjust the existing
refilling schedule as necessary;
ii. Coordinate with existing private suppliers to ramp up their capacity
in the event of
a surge; and
iii. Consider the use of oxygen concentrators for patients not needing
High Flow Nasal Cannula or mechanical ventilators. Based on the
World Health Organization, oxygen concentrators are
recommended for facilities which have limited access to oxygen
plants and refilling stations.
5. During a community surge response stage, all hospitals shall comply with the
increase in dedicated beds upon the notification or issuance from their respective
CHDs. At this stage, all hospitals shall coordinate with their respective Regional
One Hospital Command Centers for proper patient navigation.

VI. ROLES AND RESPONSIBILITIES

These offices shall perform the following roles and responsibilities:
A. Field Implementation and Coordination Team (FICT)
I. Coordinate with concerned Central Office units to provide technical assistance to
CHDs, Local Government Units, and health facilities regarding their COVID-19
response.
B. Epidemiology Bureau (EB)
1. Communicate to CHDs areas with high Alert Levels; and
2. Provide technical assistance to CHDs on surveillance and monitoring indicators
with regard to cases, among others.
C. One Hospital Command Center (OHCC)
1. Provide technical assistance and support on implementing and operationalizing the
Regional OHCCs;
2. Coordinate and link regional OHCCs to respective health facilities on patient
referral and navigation at the national level; and
3. Provide regular data on health facilities with high emergency department
occupancy rate and referrals and flag EB, coordinating offices and CHDs.
D. Health Emergency Management Bureau (HEMB)
1. Provide technical assistance on the development of surge capacity plans in relation
to other emergency and disaster plans;
 Provide logistical and funding support to health facilities to address their surge
capacity requirements; and
Assist in coordination and partnership with relevant stakeholders to ensure
continuity of operations.
E. Health Facility Development Bureau (HFDB)
I. Provide technical assistance to CHDs on monitoring province/city level indicators
with regard to health facilities.
F. Health Facility Enhancement Program (HFEP)
1. Prioritize the upgrading of existing oxygen generating plants in the DOH
Hospitals, and building of an oxygen generating plant in regions with no existing
hospital oxygen plants.
G. Centers for Health and Development (CHD)
L. Monitor indicatorsat
and
the province/city level for the region, determine the stage of
communicate their status to health facilities and LGUs to
surge response,
guide their local planning;
Provide and/or facilitate the provision of technical assistance to health facilities
and LGUs depending on the stage;

Regulate the increase and decrease of COVID-19 dedicated beds in regions

depending on the stage of response as necessary through the Regulation, Licensing
and Enforcement Divisions (RLEDs) in accordance with Department Circular No.
2020-0406;
Monitor essential supplies for COVID-19 (e.g. oxygen) in the region and assist
both public and private health facilities in planning for health facility
requirements; and
Through the Regional OHCCs, monitor and ensure reporting of health facilities to
the OHCC module of the DOH Data Collect Bed Tracker, submit required reports
to the National OHCC, and navigate and refer patients within the region.
H. PhilHealth
1. Implement financing mechanisms (i.e. Debit-Credit Payment Method) which will
support health facilities during a COVID-19 surge.
 I. Local Government Units (LGU)
1. Ensure contingency plans for their catchment area are in place;
2. Monitor the implementation of the listed action points of health facilities in their
catchment area; and
3. Provide necessary assistance (i.e. reopen Temporary Treatment and Monitoring
Facilities) to health facilities depending on the surge response stage.
J. Health Facilities
1. Ensure that their facilities’ contingency plans are in place.
2. Monitor facility level indicators every week and report to CHDs when indicated.
3. Increase the percent of their COVID-19 dedicated beds upon the issuance of the
Regional Order from CHDs.

VII. SEPARABILITY CLAUSE

If any of the provisions under this Order is declared unauthorized or rendered invalid by
any court of law or competent authority, those provisions not affected thereby shall remain valid
and effective.

VIII. EFFECTIVITY
This Order shall take effect immediately upon its publication in the Official Gazette or in
a newspaper of general circulation, with three (3) certified copies to be filed with the Office of
the National Administrative Register (ONAR) of the UP Law Center.

F OT. DUQUE I11, MD, MSe

Secretary of Health
ANNEX A. COVID-19 Surge Response at Two (2) Levels: CHD/ LGU vs Facility Response

op
IEE:
I=—
Er
CHD/ LGU Surge Response Facility Surge Response

Surge in the community (province/region) Surge in the facility

Trigger of response for all health facilities in Trigger
the area (province/region)
of facility surge plans

CHDs/LGUSs supported by Central Office Health Facility

ANNEX B. CHD/ LGU Response for Health Facilities
Table 1.1. Thresholds of the 3 Stages of CHD/ LGU Surge Response for Health Facilities

Preparedness Stage Response Stage Surge Response Stage

Description No surge in the area Anticipated surge in Surge in the area

the area (ie.
identified variant in
the area)

Criteria Alert Levels 1-2 Alert Level 3 Alert Level 4

Note: When 50% or more provinces in the region are at Alert Level 4 OR more than 70%
utilization of region’s ICU beds or hospital beds is reached, CHDs shall issue a Regional Order
instructing a region-wide increase of dedicated beds to at least 50% for government hospitals
and 30% for private hospitals.
Table 1.2. Action points for LGUs and CHDs in the 3 Stages of
COVID-19 Community Surge Response

Action Point/s Preparedness Stage Response Stage Surge Response Stage

Description No surge in the area [Anticipated surge in the area Surge in the area
(i.e. identified variant in the
area)
Criteria All indicators below Any indicator in the response Any indicator that reached
threshold threshold that is fulfilled surge threshold

LGUs and CHDs |Ensure/monitor 1. Ensure/monitor 30% of |1. Ensure/monitor 50% of

a. COVID beds health facilities have government beds and government beds and
contingency plans in 20% of private beds for 30% of private beds for
the 5 major areas: COVID-19 response COVID-19 response
2. Assist hospitals with ED 2. Direct patients to other
1.COVID-19 beds boarding hospitals who can
including the accommodate patients
essential medicines,
b. ICU beds For Level 2 and 3 hospitals, For Level and 3 hospitals,
2
oxygen, and other ensure 15% of ALL ensure 30% of ALL
supplies;
DEDICATED BEDS are DEDICATED BEDS are
2. ICU beds;
ICU beds ICU beds**
3. TTMF beds/Home
c. TTMF/ care; 1. Reopen TTMFs (% Emphasize Home Care***
Home Care 4. HRH LGUs) to health facilities to
augmentation; and 2. Ready infrastructure and decongest TTMFs
5. HRH support. HR 10 support home care
in the area (% public and
private facilities)
d. HRH Identify doctors and nurses Deploy of doctors and
augmentation ready for possible nurses to health facilities in
deployment surge
e. HRH support Contract hotels for mild CHD assistance: HRH
HRH cases transportation and
accommodation
Other Prepare of EOC/ 1. Activate EOC/Regional 1. Request assistance
interventions Regional OHCC* OHCC* from the National
2. Heighten contact tracing Government — DOH,
3. Increase targeted testing NTF, etc

*depending on the region, Emergency Operations Center (EOC) or One Hospital Command Center (OHCC)
**percentage accounts for the possible increase in cases due to COVID-19 variants
**¥ollowing latest guidelines and standards on Home Care

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ANNEX C. Facility Surge Response
Table 2.1. Thresholds and Target Dedicated Beds of the 3 Stages of Facility Surge Response

Preparedness Stage Response Stage Surge Response Stage

Action Point: % of 30% identified beds for 30-50% dedicated beds 50% dedicated beds or
ABC that are COVID- gov't; 20% for private for gov't; more for gov't;
19 dedicated beds* 20-30% for private 30% for private

Description No surge in the facility Before the surge in the Surge within the facility
Sacility

Criteria All indicators are ANY indicator is ANY indicator is fulfilled

Sulfilled Sulfilled

Risk Classification of Low Moderate High

community
(province/region)

Proportion of Less than 50% 50-70% occupancy of More than 70%

dedicated COVID-19 occupancy of preparedness stage occupancy of response
hospital beds preparedness stage dedicated beds stage dedicated beds
occupied dedicated beds

Proportion of Less than 50% 50-70% occupancy of More than 70%

dedicated COVID-19 occupancy of preparedness stage occupancy of response
ICU beds occupied** preparedness stage dedicated beds stage dedicated beds
dedicated beds

Human Resources for Less than 5% of HRH 5-10% HRH are More than 10% HRH are
Health are unavailable unavailable unavailable
unavailability***

Emergency Department Indicators

ED consults **** No increase from 1-1.5 times increase >1.5 times increase
baseline from the baseline from the baseline

Is there ED No ® Yes ® Yes

Boarding for non ® Hospital has the ® Hospital has NO
critical COVID-19 capacity to capacity to increase
cases? increase # of beds the # of beds

1
 Is there ED No Yes Yes
Boarding for Hospital has the Hospital has NO
COVID-19 critical capacity to capacity to increase
cases? increase # of ICU the # of ICU beds/
beds/ ICU ready ICU ready beds
beds

*Exception: COVID-19 Referral Hospitals

**ndicator is not applicable for Level 1 hospitals
**4Number of human resources for health quarantined and isolated out of human resources assigned to COVID-19
areas
****Totul cases seen at the ED based on duily census

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Table 2.2. Action points for Health Facilities in the 3 Stages of
COVID-19 Facility Surge Response
Preparedness Stage Response Stage Surge Response Stage

Description No surge in the facility Before the surge in the Surge within the facility
Sacility

Criteria All indicators below Any indicator in the Any indicator that reached
threshold response threshold that surge threshold
is
fulfilled

Health Facility Ensure surge plans Dedicate 30% of 1. Dedicate 50% of

a. COVID beds for hospitals are in gov't beds and 20% government beds and
place (Identify beds of private beds for 30% of private beds for
for conversion for COVID-19 response COVID-19 response
the different stages) Facilitate 2. Construct modular
Identify 30% of admissions/ hospitals to augment
gov't beds and 20% discharge (hospital hospital beds
of private beds for policy)
COVID-19
ICU beds For Level 2and 3 For Level 2 and 3 hospitals,
:
b.
response
hospitals, ensure [5% of [ensure 30% of ALL
ALL DEDICATED DEDICATED BEDS are
BEDS are ICU beds (or ICU beds (or ICU ready
ICU ready beds) beds)
¢. TTMF/ Plan for Home Care 1. Transfer mild, 1. Suspend face-to-face
Home Care infrastructure asymptomatic, step OPD services and
Use telemedicine as down care patients elective surgeries in
alternative for from Hospitals to hospitals
COVID-19 and TTMFs 2. Provide of Home Care
non-COVID-19 2. Limit face-to-face Services
consultations and OPD services and
triage elective surgeries in
hospitals

d. HRH Ensure contingency 1. Organize HRH into Accept deployment of HRH

augmentation plans for HRH are COVID-19 duty
in place and teams
communicated 2. Prepare contingency

fe
Ensure Infection request for HRH
HRH support Provide transportation and
: -
e.
Prevention and CHDS/NGA
accommodation with the
Control measures
.
3. Identify and control
help of LGU/CHD
are in place sources of HRH
Re-train HRH on infection*
COVID-19 topics
*See Department Circular 2021-0168. “Recommendations to Address the Rising Numbers of Healthcare Workers
Infected by COVID-19"

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