Triage of Suspected COIVD-19 Patients in non-US Healthcare Settings

  • Edits to make clear how healthcare employees can shield themselves throughout triage
  • Update to triage algorithm to permit for fever (>38°C) OR historical past of fever

This doc is supplied by CDC to be used in non-US healthcare settings.

This slide deck is a reference for content material on this web page and can be utilized for coaching.

S.O.P. for Triage of Suspected COVID-19 Patients in non-US Healthcare Settings

This device is for use to evaluate the triage course of primarily based on this Standard Operating Procedure (SOP).

Checklist and Monitoring Tool for Triage of Suspected COVID-19 Cases in Non-US Healthcare Settings

1. Background/Purpose

This doc is meant for healthcare amenities which are receiving or are making ready to obtain sufferers with suspected or confirmed coronavirus illness 2019 (COVID-19). This consists of healthcare amenities offering both inpatient or outpatient companies.  It must be used to information implementation of procedures at triage that may be efficient at stopping transmission of SARS-CoV-2 (COVID-19 virus) to sufferers and healthcare employees (HCWs). This doc was developed primarily based on present knowledge on COVID-19 and expertise with different respiratory viruses and will likely be up to date as extra data turns into accessible.

1.1 What is triage

The finding out and classificationexternal icon of patientsexternal icon or casualties to find out precedence of want and correct place of treatmentexternal icon.1      During infectious illness outbreaks, triage is especially vital to separate sufferers more likely to be contaminated with the pathogen of concern.  This triage SOP is developed within the context of the COVID-19 pandemic and doesn’t substitute any routine scientific triage already in place in healthcare amenities (e.g. Manchester triage system or equal) to categorize sufferers into completely different urgency classes.

1.2 COVID-19 transmission

The major route of transmission of COVID-19 is thru respiratory droplets generated when an contaminated individual coughs or sneezes.  Any one that is in shut contact with somebody who has respiratory signs (e.g., sneezing, coughing, and many others.) is vulnerable to being uncovered to probably infective respiratory droplets.2   Droplets may land on surfaces the place the virus may stay viable for a number of hours to days. Transmission by means of contact of arms with contaminated surfaces can happen following contact with the individual’s mucosa resembling nostril, mouth and eyes.

2. What sufferers can do earlier than and upon arrival to a healthcare facility

  • Inform healthcare suppliers if they’re in search of take care of respiratory signs (e.g. cough, fever, shortness of breath) by calling forward of time
  • Wear a facemask, if accessible, throughout transport and whereas at triage within the healthcare facility
  • Notify triage registration desk about respiratory signs as quickly as they arrive
  • Wash arms at healthcare facility entrance with cleaning soap and water or alcohol-based hand rub
  • Carry paper or cloth tissues to cowl mouth or nostril when coughing or sneezing. Dispose paper tissues in a trash can instantly after use
  • Maintain social distance by staying no less than one meter away, each time attainable, from anybody, together with anybody that’s with the affected person (e.g., companion or caregiver)

3. What healthcare amenities can do to attenuate danger of an infection amongst sufferers and healthcare employees

Communicate with sufferers earlier than arriving for triage

  • Establish a hotline that:
    • Patients can name or textual content notifying the ability that they’re in search of care on account of respiratory signs
    • Can be used, if attainable, as phone session for sufferers to find out the necessity to go to a healthcare facility.
    • Serves to tell sufferers of preventive measures to take as they arrive to the ability (e.g., sporting masks, having tissues to cowl cough or sneeze).
  • Provide data to most people by means of native mass media resembling radio, tv, newspapers, and social media platforms about availability of a hotline and the indicators and signs of COVID-19.
  • Healthcare amenities, along side nationwide authorities, ought to think about telemedicine (e.g., cellular phone videoconference or teleconference) to supply scientific assist with out direct contact with the affected person.3

Set up and equip triage

  • Have clear indicators on the entrance of the ability directing sufferers with respiratory signs to instantly report back to the registration desk within the emergency division or on the unit they’re in search of care (e.g., maternity, pediatric, HIV clinic) (Appendix 1). Facilities ought to think about having a separate registration desk for sufferers coming in with respiratory signs, particularly on the emergency departments, and clear indicators on the entrance directing sufferers to the designated registration desk.
  • Ensure availability of facemasks and paper tissue at registration desk, in addition to close by hand hygiene stations. A bin with lid must be accessible at triage the place sufferers can discard used paper tissues.
  • Install bodily boundaries (e.g., glass or plastic screens) for registration desk (i.e., reception space) to restrict shut contact between registration desk personnel and probably infectious sufferers.
  • Ensure availability of hand hygiene stations in triage space, together with ready areas.
  • Post visible alerts on the entrance of the ability and in strategic areas (e.g., ready areas or elevators) about respiratory hygiene and cough etiquette and social distancing. This consists of the right way to cowl nostril and mouth when coughing or sneezing and disposal of contaminated gadgets in trash cans. (Appendix 2)
  • Assign devoted scientific workers (e.g. physicians or nurses) for bodily analysis of sufferers presenting with respiratory signs at triage. These workers must be skilled on triage procedures, COVID-19 case definition, and acceptable private protecting tools (PPE) use (i.e., masks, eye safety, robe and gloves).
  • Train administrative personnel working within the reception of sufferers on the right way to carry out hand hygiene, keep acceptable distance, and on the right way to recommendation sufferers correctly on using facemask, hand hygiene, and separation from different sufferers.
  • A standardized triage algorithm/questionnaire must be accessible to be used and may embrace questions that may decide if the affected person meets the COVID-19 case definition4 (Appendix 3). HCWs must be inspired to have a excessive stage of scientific suspicion of COVID-19 given the worldwide pandemic.

Set up a “respiratory waiting area” for suspected COVID-19 sufferers

  • Healthcare amenities with out sufficient single isolation rooms or these situated in areas with excessive neighborhood transmission ought to designate a separate, well-ventilated space the place sufferers at excessive danger* for COVID-19 can wait. This space ought to have benches, stalls or chairs separated by no less than one meter distance. Respiratory ready areas ought to have devoted bathrooms and hand hygiene stations.
  • Post clear indicators informing sufferers of the placement of “respiratory waiting areas.” Train the registration desk workers to direct sufferers instantly to those areas after registration.
  • Provide paper tissues, alcohol-based hand rub, and trash bin with lid for the “respiratory waiting area.”
  • Develop a course of to scale back the period of time sufferers are within the “respiratory waiting area,” which can embrace:
    • Allocation of extra workers to triage sufferers at excessive danger for COVID-19
    • Setting up a notification system that permits sufferers to attend in a private car or outdoors of the ability (if medically acceptable) in a spot that social distance may be maintained and be notified by cellphone or different distant strategies when it’s their flip to be evaluated.

Triage course of

  • A facemask must be given to sufferers with respiratory signs as quickly as they get to the ability if they don’t have already got one. All sufferers within the “respiratory waiting area” ought to put on a facemask.
  • If facemasks aren’t accessible, present paper tissues or request the affected person to cowl their nostril and mouth with a shawl, bandana, or T-shirt throughout your complete triage course of, together with whereas within the “respiratory waiting area”. A selfmade masks with fabric can be used as supply management, if the affected person has one. Caution must be exercised as this stuff will turn out to be contaminated and might function a supply of transmission to different sufferers and even relations. WHO’s steerage must be adopted by sufferers and relations to scrub this stuff. (https://www.who.int/news-room/q-a-detail/q-a-on-infection-prevention-and-control-for-health-care-workers-caring-for-patients-with-suspected-or-confirmed-2019-ncovexternal icon).
  • Follow triage protocol (Appendix 3) and instantly isolate/separate sufferers at excessive danger* for COVID-19 in single-person rooms with doorways closed or designated “respiratory waiting areas.”
  • Limit the variety of accompanying relations within the ready space for suspected COVID-19 sufferers (nobody lower than 18 years outdated until a affected person or a mum or dad). Anyone within the “respiratory waiting area” ought to put on a facemask.
  • Triage space, together with “respiratory waiting areas,” must be cleaned no less than twice a day with a give attention to often touched surfaces. Disinfection may be completed with 0.1% (1000ppm) chlorine or 70% alcohol for surfaces that don’t tolerate chlorine. For giant blood and physique fluid spills, 0.5% (5000ppm) chlorine is really helpful. (Appendix 4).5

*definition of sufferers at excessive danger for COVID-19 will change relying on the place international locations are within the stage of outbreak (e.g. no or restricted neighborhood transmission vs. widespread neighborhood transmission). See Appendix 2 for the completely different epidemiologic eventualities.  

4. What healthcare employees (HCWs) can do to guard themselves and their sufferers throughout triage

  • All HCWs ought to adhere to Standard Precautions, which incorporates hand hygiene, choice of PPE primarily based danger evaluation, respiratory hygiene, clear and disinfection and injection security practices.
  • All HCWs must be skilled on and conversant in IPC precautions (e.g. contact and droplet precautions, acceptable hand hygiene, donning and doffing of PPE) associated to COVID-19.
    • Follow acceptable PPE donning and doffing steps (Appendix 5).
    • Perform hand hygiene often with an alcohol-based hand rub in case your arms aren’t visibly soiled or with cleaning soap and water if arms are soiled.
  • HCWs who are available in contact with suspected or confirmed COVID-19 sufferers ought to put on acceptable PPE:
    • HCWs in triage space who’re conducting preliminary screening don’t require PPE in the event that they DO NOT have direct contact with the affected person and MAINTAIN distance of no less than one meter. Examples:
      • HCWs on the registration desk which are asking restricted questions primarily based on triage protocol. Installation of bodily boundaries (e.g., glass or plastic screens) are inspired if attainable.
      • HCWs offering facemasks or taking temperatures with infrared thermometers so long as spatial distance may be safely maintained.
      • When bodily distance is NOT possible and but NO direct contact with sufferers, use masks and eye safety (face defend or goggles).
    • HCWs conducing bodily examination of sufferers with respiratory signs ought to put on robes, gloves, medical masks and eye safety (goggles or face defend).
    • Cleaners in triage, ready and examination areas ought to put on robe, heavy obligation gloves, medical masks, eye safety (if danger of splash from natural materials or chemical), boots or closed work footwear.
  • HCWs who develop respiratory signs (e.g., cough, shortness of breath) ought to keep dwelling and never carry out triage or every other duties on the healthcare facility.
  • Ensure that environmental cleansing and disinfection procedures are adopted persistently and accurately (https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for-covid-19) .

5. Additional issues for triage in periods of neighborhood transmission

  • Begin or reinforce present alternate options to face-to-face triage and visits resembling telemedicine3.
  • Designate an space close to the ability (e.g., an ancillary constructing or short-term construction) or determine a location within the space to be a “respiratory virus evaluation center” the place sufferers with fever or respiratory signs can search analysis and care.
  • Expand hours of operation, if attainable, to restrict crowding at triage throughout peak hours.
  • Cancel non-urgent outpatient visits to make sure sufficient HCWs can be found to supply assist for COVID-19 scientific care, together with triage companies. Critical or pressing outpatient visits (e.g. toddler vaccination or prenatal checkup for high-risk being pregnant) ought to proceed, nevertheless, amenities ought to guarantee separate/devoted entry for sufferers coming for vital outpatient visits to not place them vulnerable to COVID-19.
  • Consider suspending or cancelling elective procedures and surgical procedures relying on the native epidemiologic context.

6. References

  1. Medical Dictionary. Available at. https://www.online-medical-dictionary.org/definitions-t/triage.htmlexternal icon. Accessed on March 18.2020
  2. World Health Organization. Infection prevention and management throughout well being care when novel coronavirus (nCoV) an infection is suspected. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125external icon. Accessed on March 13, 2020
  3. World Health Organization. Telemedicine: alternatives and developments in Member States: report on the second world survey on eHealth. Global Observatory for eHealth Series, 2, World Health Organization. 2009.
  4. World Health Organization. Global Surveillance for human an infection with coronavirus illness (COVID-19). Available at https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)external icon. Accessed on March 13, 2020
  5. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal brokers. J Hosp Infect. 2020 Mar;104(3):246-251. doi: 10.1016/j.jhin.2020.01.022.

7. Acknowledgements

CDC wish to acknowledge April Baller, MD,  Infection Prevention and Control Lead, WHO Health Emergency and Maria Clara Padoveze, RN, PhD, Technical officer, IPC unit, WHO  for his or her priceless contributions to this SOP.

Appendix 1: Visual Alert to Direct Patient with Respiratory Symptoms

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