Coronavirus-19 Pandemic: A Two-step Triage Protocol for Emergency Department

Dear Editor,

The world is reeling under the treat of the novel corona virus with hundreds of people dying every day.[1] Every epidemic in a country goes through four phases: Phase1, introduction or emergence in the community; Phase 2, local transmission; Phase 3, amplification; Phase 4, reduced transmission immunity.[2] For an emergency physician, who is at the frontline of the health delivery system, it is crucial to develop a mechanism during the Phase 2 and 3, where the patients with the disease are identified and properly isolated without getting themselves and other patients infected in the process. As the pandemic is progressing through different stages, we suggest a system of a two-step triage of the suspected cases.

“PRE”-TRIAGE

During the Phase 2, when there are sporadic infections, the priority is early identification and isolation. There will be spike of ambulatory patients, with flu-like symptoms flooding the emergency department (ER) with concerns of coronavirus-19 (COVID19). There are two ways a patient can come to the ER: one is the preinformed transfer of a confirmed/suspected case from a different facility and the second is when a patient with mild symptoms walks in the ER. In the former scenario, the designated triage nurse/doctor can route the patient directly to the isolation ward or intensive care unit based on the physiologic status of the patient.

The second set of patients with symptoms who walk in directly to the ER have to be “pre”-triaged before being triaged based on physiological parameters. A designated nurse or doctor at a separated ED triage desk will ask focused questions about symptoms, history of travel, and history of contacts. As per the case definition of covid-19,[3] a checklist [Table 1] will be made to screen all patients, which will ensure that no suspicious case is left out. Use of telemedicine at this point is also suggested.[4] Once the case is identified, they should be immediately shifted to an isolation ward where further triaging will be done of physiological parameters. A separate “pre”-triage system with restricted activity of health-care workers (HCWs) and patients will prevent cross-infection. This way, normal patient flow is segregated from the suspected cases of corona virus [Figure 1].

Table 1.

Pretriage checklist for coronavirus 19

Pretriage checklist for COVID19
NAme:	Sex/Age:	Address:
Symptoms	Fever
	Cough
	Breathlessness
	Sore throat
	Rhinorrhea
	NAusea/vomiting
	Diarrhea
Vitals	SPO2
	Temperature
History of travel	Recent travel to any country with COVID19 outbreak
	Specify – Date of travel
History of contact	Any contact with confirmed or suspected case of COVID19 Yes/no
Any co-morbid illness	Yes/no if yes, specify
COVID19 testing done	Yes/no if yes, results
Decision	Shift to isolation unit
	Send for home quarantine
	Shift to routine ED

COVID19: Coronavirus, ED: Emergency department

Figure 1.

Flow of patients of suspected/diagnosed cases of coronavirus-19

During the Phase 3, when there will be a surge of red and yellow patients, it is expected that systems may be overwhelmed. Important consideration here is activation of “Code Red/Code Blue.” Christian et al. in their observation during the severe acute respiratory syndrome outbreak found a high chance of spread of infections to HCWs during resuscitation.[5] The emergency physician should decide the usefulness of resuscitation in each case, especially in cases of unwitnessed arrests and should call off resuscitation if the outcome is grim. A separate triage category for patients coming in extremis should be made, labeled blue or gray, where decision to resuscitate is made on case to case basis. As the case load increases, the hospital may eventually resort to “reverse triage.”[6]

In conclusion, every ER should create a contingency plan to “pre”-triage the suspected COVID-19 patients to limit the spread of the disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.