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Triage
This forms one section of our COVID-19 Emergency Department Assessment & Management Guideline
Summary
- Patients considered to be “at risk of transmitting COVID-19 infection” to staff and other patients should be identified in a formalised process and provided a surgical mask to wear.
- The definition of “at risk” patients will vary between jurisdiction and with time so consult local guidelines.
- The “at risk” patient definition is different to the local “COVID testing criteria” – the latter is not relevant to triage.
- Well patients should be directed to another service if available (e.g. purpose designed “COVID Clinic”) or directed home by the triage staff member, as appropriate, according to a locally agreed protocol.
- Patients requiring ED assessment should be provided the highest level of isolation that balances the patient’s clinical risk of infectivity and the available methods of isolation – a methodology for ranking isolation effectiveness of ED spaces and prioritising patient’s access to these spaces is provided below.
- Critically unwell patients will need to be managed in repurposed non-traditional resuscitation areas (e.g. negative pressure areas/single rooms) or traditional resuscitation areas may require temporary installation of barriers to improve infection control properties.
- Triage staff should wear PPE appropriate for the routine care of patients.
Initial Triage
Patients considered to be “at risk of transmitting COVID-19 infection” to staff and other patients should be identified at, or ideally before, Emergency Department (ED) triage in a formalised process and provided a surgical mask to wear. Note that it is not relevant whether these “at risk” patients meet formal criteria for diagnostic testing, as the latter criteria are based on a balance between population risks and availability of testing resources as opposed to risk to staff and other ED patients of contracting infection from patients.
The definition of a patient “at risk”of transmitting COVID-19 infection” and the definition of patients who meet “formal criteria for testing” will vary between jurisdictions and may change frequently so consult local guidelines.
While waiting for triage, at risk patients should be separated from the general waiting room in an appropriate clinical or non-clinical area, inside or outside of the department, with sufficient distancing between patients.
Post triage disposition and cohorting:
Well patients should be directed to another service if available (e.g. purpose designed “COVID Clinic”) or directed home by the staff member (nurse and/or doctor) as appropriate according to a locally agreed protocol that balances the small additional risks incurred by well looking patients from this accelerated brief assessment and the risks to the community of disease spread that are minimised by directing these patients away from the ED. Triage staff should wear PPE appropriate for the routine care of patients.
Patients requiring an ED assessment should be provided the highest level of isolation that balances the patient’s clinical risk of infectivity and the available methods of isolation. The available methods of isolation in ED ranked in decreasing effectiveness are (ACEM):
- Negative pressure isolation room
- Single room with door shut
- Single room without door (curtain shut)
- Curtained cubicles with curtains closed.
- Waiting room with 1.5m distance of separation.
Where lower levels of isolation are used, suspected COVID-19 patients should be grouped within the same geographical area. In regions where COVID-19 has become endemic with high levels of community disease, availability of higher level isolation spaces will be overwhelmed by demand and large sections of a department may need to be used to cohort “at risk” patients.
In order of priority, preference for treatment spaces with the highest levels of isolation should be given to (ACEM):
1. Patients with suspected or confirmed COVID-19 who are undergoing, or are likely to undergo, an aerosol generating procedure or event (AGP)
2. Patients with suspected COVID-19 receiving supplemental oxygen.
3. Other patients with confirmed COVID-19.
4. Other patients with suspected COVID-19.
Critically unwell patients need to be managed in an appropriate clinical area for their needs while maintaining safe protection of staff. Non-traditional resuscitation areas (negative pressure rooms, single rooms), may require repurposing for the care of the critically ill if they have better infection control properties than the traditional resuscitation area which is usually an open plan design without airflow control. Where that is not possible, temporary barriers will require installation to separate clinical areas within traditional resuscitation areas such as lightweight temporary walls and plastic sheeting.