Customary Working Process (SOP) for Triage of Suspected COVID-19 Sufferers in non-US Healthcare Settings: Early Identification and Prevention of Transmission throughout Triage

  • Changes to clarify how healthcare workers can protect themselves during triage
  • Update the triage algorithm to include a history of fever (> 38 ° C) OR fever

This document is provided by CDC for use in non-US healthcare facilities.

This slide deck is a reference for the contents of this page and can be used for training purposes.

This tool is used to evaluate the triage process on the basis of these Standard Operating Instructions (SOP).

Checklist and Monitoring Tool for Triage of Suspicious COVID-19 Cases in Non-US Healthcare Facilities

1. Background / purpose

This document is intended for healthcare facilities receiving or preparing patients with suspected or confirmed coronavirus disease 2019 (COVID-19). This includes healthcare facilities that provide either inpatient or outpatient services. It should be used to guide the implementation of triage procedures that can effectively prevent the transmission of SARS-CoV-2 (COVID-19 virus) to patients and healthcare workers (HCW). This document was developed based on current data on COVID-19 and experience with other respiratory viruses and will be updated as more information becomes available.

1.1 What is triage?

Sorting out and classifyingexternal symbol

1.2 COVID-19 transmission

The main route of transmission of COVID-19 is via respiratory droplets, which are produced when an infected person coughs or sneezes. Anyone who is in close contact with someone who has difficulty breathing (e.g., sneezing, coughing, etc.) is at risk of potentially infectious respiratory droplets.2 Droplets can also land on surfaces that have the virus on could remain viable for several hours to days. Transmission through contact of hands with contaminated surfaces can occur after contact with the mucous membrane of the person such as the nose, mouth and eyes.

2. What patients can do before and after arriving at a healthcare facility

  • Let healthcare providers know if they want to take care of respiratory problems (e.g. cough, fever, shortness of breath) by calling early
  • If available, wear a face mask during transportation and triage at the healthcare facility
  • Notify the Triage Registration Desk of any respiratory symptoms as they occur
  • Wash your hands with soap and water or hand-based alcohol at the entrance to the healthcare facility
  • Wear paper or cloth to cover your mouth or nose when you cough or sneeze. Dispose of paper tissues in a trash can immediately after use
  • Maintain social distance by staying at least three feet away from people whenever possible, including those around the patient (e.g. companions or caregivers).

3. What can healthcare institutions do to minimize the risk of infection for patients and healthcare workers?

Communicate with patients before coming to triage

  • Set up a hotline that:
    • Patients can call or text the facility that they are seeking treatment for respiratory problems
    • If possible, can be used as a telephone consultation for patients to determine if a health facility needs to be visited.
    • Used to inform patients of preventive measures to take when entering the facility (e.g., wear a mask, have handkerchiefs to prevent coughing or sneezing).
  • Providing information to the general public through local mass media such as radio, television, newspapers and social media about hotline availability and the signs and symptoms of COVID-19.
  • Healthcare facilities, in collaboration with national authorities, should consider telemedicine (e.g. video conferencing or conference call for cell phones) to provide clinical support without direct contact with the patient. 3

Set up and equip triage

  • Have clear signs at the entrance to the facility instructing patients with respiratory symptoms to report immediately to the registration desk in the emergency room or in the department they care for (e.g. maternity, children's, HIV clinic) (Appendix 1 ). Facilities should consider having a separate registration desk for patients with respiratory symptoms, especially in the emergency room, and clear signs at the entrance directing patients to the designated registration desk.
  • Ensure the availability of face masks and tissues at the registration desk as well as at nearby hand hygiene stations. For triage, a container with a lid should be available in which patients can dispose of used tissues.
  • Install physical barriers (such as glass or plastic screens) for the registration desk (i.e., the reception area) to limit close contact between the registration desk staff and potentially infectious patients.
  • Ensure the availability of hand hygiene stations in the triage area, including the waiting areas.
  • Post visual warnings at the facility entrance and in strategic areas (e.g., waiting areas or elevators) about respiratory hygiene, cough etiquette, and social distancing. This includes covering your nose and mouth when coughing or sneezing, and disposing of contaminated items in bins. (Appendix 2)
  • Assign dedicated clinical personnel (e.g., doctors or nurses) to the physical evaluation of patients with respiratory symptoms during triage. These personnel should be trained in triage procedures, COVID-19 case definition, and appropriate use of personal protective equipment (PPE) (i.e. mask, eye protection, robe and gloves).
  • To train administrative staff working on patient admission in the practice of hand hygiene, keeping appropriate distances and properly advising patients on face masks, hand hygiene and separation from other patients.
  • A standardized triage algorithm / questionnaire should be available and contain questions that determine whether the patient meets the COVID-19 case definition4 (Appendix 3). HCWs should be encouraged to have high clinical suspicions of COVID-19 in the face of the global pandemic.

Establish a "respiratory waiting area" for suspected COVID-19 patients

  • Healthcare facilities without enough individual isolation rooms, or those in areas with high community exposure, should designate a separate, well-ventilated area for patients at high risk * for COVID-19 to wait. This area should have benches, stands, or chairs at least three feet apart. Breathing holding areas should have special toilets and hand hygiene stations.
  • Put up clear signs informing patients of the location of the “airway waiting areas”. Train the staff at the registration office to direct patients to these areas immediately after registration.
  • Provide paper towels, alcohol-based hand massage and garbage cans with lids for the "airway waiting area".
  • Develop a process to reduce the time patients spend in the “airway waiting area”. This can include:
    • Assign additional staff to triage patients at high risk for COVID-19
    • Establish a notification system that will allow patients to wait in a personal vehicle or outside the facility (if medically appropriate) in a place where social distance can be maintained and notified by phone or other remote means when it is their turn to be assessed to become .

Triage process

  • Patients with respiratory symptoms should be given a face mask once they reach the facility if they don't already have one. All patients in the “airway waiting area” should wear a face mask.
  • If face masks are not available, provide tissues or ask the patient to cover the nose and mouth with a scarf, headscarf or T-shirt during the entire triage process, including in the "airway waiting area". A homemade mask with fabric can also be used as source control in case the patient has one. Care should be taken as these items become contaminated and can serve as a source of transmission for other patients or even family members. WHO instructions should be followed by patients and family members to clean these items. (https://www.who.int/news-room/qa-detail/qa-on-infection-prevention-and-control-for-health-care-workers-caring-for-patients-with-suspected-or -confirmed-2019-ncovexternal symbol
  • Follow the Triage Protocol (Appendix 3) and immediately isolate / segregate high risk * patients for COVID-19 in single rooms with closed doors or designated “airway waiting areas”.
  • Limit the number of accompanying family members in the waiting area for suspicious COVID-19 patients (no one under the age of 18 except a patient or a parent). Anyone in the airway waiting area should wear a face mask.
  • The triage area, including the “airway waiting areas”, should be cleaned at least twice a day, with an emphasis on surfaces that are frequently touched. Disinfection can be carried out with 0.1% (1000 ppm) chlorine or 70% alcohol for surfaces that cannot tolerate chlorine. For large amounts of blood and body fluid contamination, 0.5% (5000 ppm) chlorine is recommended. (Appendix 4) 5

* The definition of patients at high risk for COVID-19 changes based on where countries are at the outbreak stage (e.g., no or limited community transmission versus widespread community transmission). See Appendix 2 for the different epidemiological scenarios.

4. What can healthcare workers do to protect themselves and their patients during triage?

  • All HCWs should follow standard precautions that include hand hygiene, selection of PPE-based risk assessment, respiratory hygiene, cleaning and disinfection, and injection safety practices.
  • All HCWs should be trained and familiar with IPC precautions (e.g., contact and drip precautions, adequate hand hygiene, putting on and taking off PPE) related to COVID-19.
    • Follow the appropriate steps to put on and take off PPE (Appendix 5).
    • Frequent hand hygiene practices include an alcohol-based hand massage if your hands are not visibly dirty, or soap and water if your hands are dirty.
  • HCWs who come in contact with suspected or confirmed COVID-19 patients should wear appropriate PPE:
    • Triage HCWs performing preliminary screening do not require PPE if they are NOT in direct contact with the patient and are at least one meter away from them. Examples:
      • HCWs at the registration desk asking limited questions based on the triage protocol. The installation of physical barriers (e.g. glass or plastic screens) is recommended whenever possible.
      • HCWs that provide face masks or measure temperatures with infrared thermometers, as long as the physical distance can be safely maintained.
      • If physical removal is not possible and there is NO direct contact with patients, use a mask and eye protection (face shield or safety glasses).
    • HCWs performing a physical exam on patients with respiratory symptoms should wear robes, gloves, medical mask, and eye protection (safety glasses or face shield).
    • Cleaners in triage, waiting and examination areas should wear a dress, high-performance gloves, a medical mask, eye protection (if there is a risk of splashes from organic material or chemicals), boots or closed work shoes.
  • HCWs who develop respiratory symptoms (e.g., cough, shortness of breath) should stay at home and avoid triage or other duties in the healthcare facility.
  • Make sure that the cleaning and disinfection procedures for the environment are followed consistently and correctly (https://www.who.int/publications-detail/water-sanitation-hygiene-and-waste-management-for-covid-19 ).

5. Additional considerations for triage during community transmission

  • Start or reinforce existing alternatives to personal triage and visits such as telemedicine3.
  • Designate an area near the facility (such as an outbuilding or temporary structure) or identify a place in the area as a "Respiratory Virus Assessment Center" for patients with fever or respiratory symptoms to seek assessment and care.
  • If possible, extend hours of operation to limit triage overcrowding during peak hours.
  • Cancel non-urgent outpatient visits to ensure there are enough HCW available to support clinical care for COVID-19, including triage services. Critical or urgent outpatient visits (e.g., infant vaccination or antenatal screening for high-risk pregnancy) should continue. However, facilities should ensure separate / dedicated access for patients coming for critical outpatient visits so as not to expose them to the risk of COVID-19.
  • Consider postponing or canceling election procedures and operations depending on the local epidemiological context.

6. References

  1. Medical dictionary. Available at. https://www.online-medical-dictionary.org/definitions-t/triage.htmlexternal symbol
  2. World health organization. Infection prevention and control in healthcare when a novel coronavirus infection (nCoV) 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 symbol
  3. World health organization. Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth. Global Observatory on eHealth Series, 2, World Health Organization. 2009.
  4. World health organization. Global surveillance for human infections with coronavirus (COVID-19). Available at https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov)external symbol
  5. Kampf G., Todt D., Pfaender S., Steinmann E. Persistence of coronaviruses on lifeless surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020 Mar; 104 (3): 246- 251. doi: 10.1016 / j.jhin.2020.01.022.

7. Acknowledgments

CDC would like to thank April Baller, MD, Head of Infection Prevention and Control, WHO Health Emergency, and Maria Clara Padoveze, RN, PhD, Technical Associate, IPC Division, WHO, for their valuable contributions to this SOP.

Appendix 1: Visual Warning to Direct Patients with Respiratory Symptoms

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