Triage in epidemics : Especially Focus On Corona Virus

  • Triage in epidemics
    Exact screening protocols may vary depending on the nature of the epidemic and its principle symptoms and etiology. However, many epidemic illness have vague or overlapping symptoms.
    During the initial phases of an epidemic when the specific etiology is unknown, it may be difficult to differentiate an illness based on symptoms alone. However, the most likely epidemics will involve primarily either respiratory or gastrointestinal symptoms and transmission.
    Triage during primary respiratory illness
     Respiratory illnesses that may constitute a public health emergency of national concern in Nepal include but are not limited to the following: Severe acute respiratory syndrome coronavirus (SARS), influenza, pneumonic plague, Middle East Respiratory Syndrome coronavirus (MERS), or other novel acute respiratory infections.
     During initial phase of epidemic, the infectious agent may be unknown. However, often there will have been outbreaks of epidemic in other locations in Nepal or other countries, which can guide the evaluation.
     Treating staff should follow algorithm in figure 5.6.1 during the initial phase of activation.
    Screening for respiratory epidemic risk factors at initial presentation should include the following:
    o Fever and
    o Cough or shortness of breath and
    o Travel to a region with a known ongoing respiratory epidemic or
    o Contact with known diagnosis of epidemic respiratory infection
     Specific triage criteria based on common infectious agents are discussed in Annex A
     Isolation and infectious precautions should be followed to the extent possible at all times. Specific guidelines for isolation and PPE use during respiratory epidemics are discussed in section 8 below.

    Figure Triage pathway for unknown epidemic at initial disaster plan activation

    Epidemic Emergency Unit (EEU) ;
     Only epidemic victims will be placed in this area from then on.
     A red triage tag will be placed above sick patient’s beds to identify them. Electrical and O2 outlets
    for patient monitoring should be installed in advance to prepare for this role. Yellow tag will be
    placed accordingly.
     Epidemic patients triaged as green who are able to sit up in a chair.
     All doors to the EEU are to remain closed at all times.
    Epidemic Disaster Supplies :
     The emergency epidemic disaster stock includes two components: medical supplies for infected
    patients and protective equipment/supplies for health care workers care for the infected.
    Health care worker Disaster Stock- PPE
     Equally important, the epidemic disaster stock should include personal protective equipment for health care workers
     Supplies should allow for universal precautions during the initial phase of an epidemic when the infectious agent and its mode of transmission are still unknown.
     These supplies should include: gowns, gloves, surgical masks, N95 masks, eye shields, and hand sanitizer or materials for compounding hand sanitizer.
     Initially, at least one PPE should be available to each staff of the hospital, stored in the disaster store. Some of these supplies may be usable for more than one use (such as surgical face masks, N95 masks, or eye shields) or washable and reusable (such as washable gowns).
    Nonetheless, since PPE may become grossly contaminated with blood or body fluids and need to be discarded
    at any point, an initial supply of at least minimum of 100 of each type of PPE depending on the capacity of hospital disaster stockpile.
     The PPE stockpile should be kept in a locked room on the epidemic ward. Supplies should be clearly labeled as epidemic disaster stockpile to be used only during the activation of the epidemic disaster plan.
     Following activation of the epidemic disaster plan, half of the supplies are to be delivered to the EEU (i.e. GPU) for use by staff in the triage and EEU areas. The other half of the supplies should remain on the epidemic ward.
     A supply of 100 masks should be provided to the screening triage station during a respiratory epidemic so they can be given to infectious patients prior to entering the hospital.
    Prevention and control of infection
    1. General principles and basic requirements
    Goal is to reduce transmission of healthcare-associated infections and improve safety of all who are
    present in hospital and ensure that the hospital does not enhance the epidemic.
     Infection control should be an ongoing hospital activity during routine hospital functions
     Ideally, a dedicated infection prevention and control staff should be trained to develop locally
    adapted technical guidelines and policies for infection control.
     Hospital staff health should be monitored continuously and a system should be implemented for
    staff to report concerning symptoms in workers.
    2. Early recognition and source control
     At initial screening, triage will send epidemic patients to the epidemic triage at EEU so that
    infectious patients are isolated from other patients.
    3. Isolation
     Since having all infectious patients in isolation in individual rooms is not currently feasible at Patan Hospital, ICS should consider the use of patient cohorting – that is, placing patients infected or colonized with the same laboratory-confirmed pathogens in the same designated unit, zone or ward (with or without the same staff) – to reduce transmission of pathogens to health-care workers and other patients. When there is no laboratory results or epidemiological surveillance data confirming a particular infectious agent, full PPE should be worn by all staff.
    Initially, the mode of transmission will be unknown. Universal precautions should always be applied. Categories of isolation must be developed and applied based on the mode of transmission of the epidemic as more information becomes available.
    requirement for specific infections.
     Avoid sharing of equipment when possible. If sharing is unavoidable, ensure that reusable equipment is appropriately disinfected between patients.
     Limit the number of people entering the assigned unit or area for isolation/cohorting to the minimum number required for patient care and support.
     Doors to all designated epidemic care areas should remain closed at all times.8.4 Personal Protective Equipment, and Staff safety
     Guidelines and protocols for appropriate use of PPE should be developed and staff should receive training in PPE use during routine hospital operations and prior to an epidemic.
     PPE should be distributed from the epidemic disaster stock pile and placed in carts located at obvious and convenient sites in the epidemic treatment areas.
    These locations include:
    o The entrance to the epidemic ward on the fourth floor.
    o Front and rear ends of the epidemic emergency unit.
    o Outside any separate isolation areas such as designated OB or pediatric isolation rooms.
    o A supply of face masks for distribution to patients and their family should be placed at screening triage in the event of a respiratory epidemic.Crowd control, management of media and relatives
    1 Crowd control
    * Is crucial because once the hospital is over-run it is impossible to work
    * Ideally the crowds are prevented from entering the clinical areas
    * In an “evolving disaster” or where no prior warning is given, the crowds often get inside the clinical areas from the start. In this case they must be gently but firmly removed
    * Certain doors must be opened or closed by security/administration, and all access points posted with guards
    * Each patient is allowed to enter the triage area with one friend/helper
    2. Management of media
    The media person will be informed timely at main gate. Media person with identity card will be allowed to enter through main gate and gather in a previously designated area only. They will not be allowed to enter other area of hospital, especially the triage and treatment areas. Once the treatment areas are in control, and with permission from HICC, the media can be taken for a controlled tour if required. No gory pictures of patients should be shot.
    The Communication officer should update the media every half hours so that they do not feel like they have nothing to do. The victims list should be printed and posted in various places including the front main gate.
    Media will addressed at ………………………………… by …………………………………………..Personnel for epidemic outbreak
     Prior to an epidemic, staff should be identified who are willing to serve in designated epidemic care areas. These staff should receive advanced training in the components of the Epidemic Disaster Subplan and their tasks during activation. They should also demonstrate proficiency in the use of PPE.
     Initially, hospital staff may be sufficient to care for epidemic patient volumes. As the number of victims surges, enrolling extra staff may be necessary including: retired hospital staff, university staff and students from schools of medicine/nursing/public health, and volunteers. Consideration should be given to how this additional staff will receive training to perform specified roles, credentialing, and supervision.
     Certain tasks do not require skilled medical care but are important to the smooth operation of the epidemic treatment areas and flow of patients (e.g. Disposing of waste, cleaning beds and other contaminated surfaces, and assisting with patient transport). These tasks may be performed by staff drawn from services such as housekeeping.
    Pharmacy and laboraroty services in epidemics
    1 Pharmacy Services
     During an epidemics, supplies of medicines for treating infectious diseases (IVF, antibiotics, antivirals, vaccines, etc.) Will be required in greater quantities. The planning officer should work with pharmacy both before and during an epidemic to ensure that the hospital has sufficient and reliable supplies of essential medicines.
     An inventory of existing pharmaceutical supplies should be developed and updated regularly by the head of pharmacy. This inventory should be made available to ICS at the start of the epidemic disaster activation.
     Limited pharmaceuticals stock piles may be maintained in case of an epidemic. However, the waste and expense of maintaining such stock piles is often prohibitive and large stocks of such medicines should be avoided. More importantly, a supply chain for obtaining larger quantities of such medications should be obtained beforehand.
    2. Laboratory services
     Laboratory investigations will increase during an infectious epidemics. The planning officer should work with the head of laboratory services both before and during an epidemic to estimate laboratory capacity. This will include equipment (such as centrifuges), testing supplies (such as viral and bacterial culture mediums) and the number of personnel on staff. Updated inventories of laboratory supplies should be maintained by the head of laboratory services.
     In addition to the increased number of investigations being ordered, a rapid turn-around time for investigations to identify the causative organism of the epidemic will expected. This may require increased personnel in the laboratory to perform testing as rapidly as possible 24 hours a day. Volunteers or staff from other departments may be recruited to support laboratory staff if needed and plans for rapidly instructing these additional emergency staff should be developed and evaluated prior to the onset of an epidemic.
     Protocols for appropriate use of laboratory testing in the epidemic ward should be developed to assist in the diagnosis of epidemic victims as rapidly as possible while also avoiding unnecessary testing.
     During the course of an epidemic, a point will be reached when confirmatory testing is no longer necessary. Such a point will vary depending on the nature of the epidemic and the sensitivity and specificity of available testing. In general, once a particular agent has been consistently identified as the causative etiology in patients with similar epidemic syndromes, furtherer laboratory investigation can be halted to spare unnecessary expense and delay in management.
    This will also relieve laboratory staff.Recommendations for triage and evaluation of epidemic victims for selected infectious
    SARS-Coronavirus or other novel coronavirus precautions
    1. Screening measures
    a. Phased escalation of precautions may be appropriate, but after the epidemic disaster subplan has been activated screening will automatically escalate from passive (e.g., signs at the entrance) to active (e.g., direct questioning at triage). In addition to visual alerts, other potential screening measures include:
     Priority triage of persons with lower respiratory symptoms
     Triage stations outside the facility to screen patients before they enter
     Telephone screening of patients with appointments
    b. In addition to asking about symptoms per the standard respiratory epidemic screening recommendations above, the screening triage nurse should ask about the following specific risk factors in the 10 days before illness onset:
     Travel to mainland China, Hong Kong, or Taiwan, the Middle East (or other country with an identified severe respiratory coronavirus outbreak) or close contact with an ill person with a history of recent travel to one of these areas, OR
     Employment in an occupation associated with a risk for SARS-cov exposure (e.g., healthcare worker with direct patient contact; worker in a laboratory that contains live SARS-cov), OR
     Part of a cluster of cases of atypical pneumonia without an alternative diagnosis
    c. Be alert for clusters of pneumonia among two or more healthcare workers who work in the same facility.
    d. Post visual alerts (in appropriate languages) at the entrances to all outpatient facilities (emergency departments, physicians’ offices, clinics) instructing patients to inform healthcare personnel of lower respiratory symptoms when they first register for care and to practice respiratory hygiene/cough etiquette precautions as described above.