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This tool is to be used to assess the triage process based on this Standard Operating Procedure (SOP).

1. Background/Purpose

This document is intended for healthcare facilities that are receiving or are preparing to receive patients with suspected or confirmed coronavirus disease 2019 (COVID-19). This includes healthcare facilities providing either inpatient or outpatient services.  It should be used to guide implementation of procedures at triage that can be effective at preventing transmission of SARS-CoV-2 (COVID-19 virus) to patients and healthcare workers (HCWs). 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.

2. What patients can do before and upon arrival to a healthcare facility

• Inform healthcare providers if they are seeking care for respiratory symptoms (e.g. cough, fever, shortness of breath) by calling ahead of time
• Wear a facemask, if available, during transport and while at triage in the healthcare facility
• Notify triage registration desk about respiratory symptoms as soon as they arrive
• Wash hands at healthcare facility entrance with soap and water or alcohol-based hand rub
• Carry paper or fabric tissues to cover mouth or nose when coughing or sneezing. Dispose paper tissues in a trash can immediately after use
• Maintain social distance by staying at least one meter away, whenever possible, from anyone, including anyone that is with the patient (e.g., companion or caregiver)

3. What healthcare facilities can do to minimize risk of infection among patients and healthcare workers

Communicate with patients before arriving for triage

• Establish a hotline that:
  • Patients can call or text notifying the facility that they are seeking care due to respiratory symptoms
  • Can be used, if possible, as telephone consultation for patients to determine the need to visit a healthcare facility.
  • Serves to inform patients of preventive measures to take as they come to the facility (e.g., wearing mask, having tissues to cover cough or sneeze).
• Provide information to the general public through local mass media such as radio, television, newspapers, and social media platforms about availability of a hotline and the signs and symptoms of COVID-19.
• Healthcare facilities, in conjunction with national authorities, should consider telemedicine (e.g., cell phone videoconference or teleconference) to provide clinical support without direct contact with the patient.³

Set up and equip triage

• Have clear signs at the entrance of the facility directing patients with respiratory symptoms to immediately report to the registration desk in the emergency department or at the unit they are seeking care (e.g., maternity, pediatric, HIV clinic) (Appendix 1). Facilities should consider having a separate registration desk for patients coming in with respiratory symptoms, especially at the emergency departments, and clear signs at the entrance directing patients to the designated registration desk.
• Ensure availability of facemasks and paper tissue at registration desk, as well as nearby hand hygiene stations. A bin with lid should be available at triage where patients can discard used paper tissues.
• Install physical barriers (e.g., glass or plastic screens) for registration desk (i.e., reception area) to limit close contact between registration desk personnel and potentially infectious patients.
• Ensure availability of hand hygiene stations in triage area, including waiting areas.
• Post visual alerts at the entrance of the facility and in strategic areas (e.g., waiting areas or elevators) about respiratory hygiene and cough etiquette and social distancing. This includes how to cover nose and mouth when coughing or sneezing and disposal of contaminated items in trash cans. (Appendix 2)
• Assign dedicated clinical staff (e.g. physicians or nurses) for physical evaluation of patients presenting with respiratory symptoms at triage. These staff should be trained on triage procedures, COVID-19 case definition, and appropriate personal protective equipment (PPE) use (i.e., mask, eye protection, gown and gloves).
• Train administrative personnel working in the reception of patients on how to perform hand hygiene, maintain appropriate distance, and on how to advice patients properly on the use of facemask, hand hygiene, and separation from other patients.
• A standardized triage algorithm/questionnaire should be available for use and should include questions that will determine if the patient meets the COVID-19 case definition⁴ (Appendix 3). HCWs should be encouraged to have a high level of clinical suspicion of COVID-19 given the global pandemic.

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

• Healthcare facilities without enough single isolation rooms or those located in areas with high community transmission should designate a separate, well-ventilated area where patients at high risk* for COVID-19 can wait. This area should have benches, stalls or chairs separated by at least one meter distance. Respiratory waiting areas should have dedicated toilets and hand hygiene stations.
• Post clear signs informing patients of the location of “respiratory waiting areas.” Train the registration desk staff to direct patients immediately to these areas after registration.
• Provide paper tissues, alcohol-based hand rub, and trash bin with lid for the “respiratory waiting area.”
• Develop a process to reduce the amount of time patients are in the “respiratory waiting area,” which may include:
  • Allocation of additional staff to triage patients at high risk for COVID-19
  • Setting up a notification system that allows patients to wait in a personal vehicle or outside of the facility (if medically appropriate) in a place that social distance can be maintained and be notified by phone or other remote methods when it is their turn to be evaluated.

Triage process

• A facemask should be given to patients with respiratory symptoms as soon as they get to the facility if they do not already have one. All patients in the “respiratory waiting area” should wear a facemask.
• If facemasks are not available, provide paper tissues or request the patient to cover their nose and mouth with a scarf, bandana, or T-shirt during the entire triage process, including while in the “respiratory waiting area”. A homemade mask with cloth can also be used as source control, if the patient has one. Caution should be exercised as these items will become contaminated and can serve as a source of transmission to other patients or even family members. WHO’s guidance should be followed by patients and family members to clean these items. (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 immediately isolate/separate patients at high risk* for COVID-19 in single-person rooms with doors closed or designated “respiratory waiting areas.”
• Limit the number of accompanying family members in the waiting area for suspected COVID-19 patients (no one less than 18 years old unless a patient or a parent). Anyone in the “respiratory waiting area” should wear a facemask.
• Triage area, including “respiratory waiting areas,” should be cleaned at least twice a day with a focus on frequently touched surfaces. Disinfection can be done with 0.1% (1000ppm) chlorine or 70% alcohol for surfaces that do not tolerate chlorine. For large blood and body fluid spills, 0.5% (5000ppm) chlorine is recommended. (Appendix 4).⁵

*definition of patients at high risk for COVID-19 will change depending on where countries are in the stage of outbreak (e.g. no or limited community transmission vs. widespread community transmission). See Appendix 2 for the different epidemiologic scenarios.  

4. What healthcare workers (HCWs) can do to protect themselves and their patients during triage

• All HCWs should adhere to Standard Precautions, which includes hand hygiene, selection of PPE based risk assessment, respiratory hygiene, clean and disinfection and injection safety practices.
• All HCWs should be trained on and familiar with IPC precautions (e.g. contact and droplet precautions, appropriate hand hygiene, donning and doffing of PPE) related to COVID-19.

• • Follow appropriate PPE donning and doffing steps (Appendix 5).
  • Perform hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty.

• HCWs who come in contact with suspected or confirmed COVID-19 patients should wear appropriate PPE:
  • HCWs in triage area who are conducting preliminary screening do not require PPE if they DO NOT have direct contact with the patient and MAINTAIN distance of at least one meter. Examples:
    • HCWs at the registration desk that are asking limited questions based on triage protocol. Installation of physical barriers (e.g., glass or plastic screens) are encouraged if possible.
    • HCWs providing facemasks or taking temperatures with infrared thermometers as long as spatial distance can be safely maintained.
    • When physical distance is NOT feasible and yet NO direct contact with patients, use mask and eye protection (face shield or goggles).
  • HCWs conducing physical examination of patients with respiratory symptoms should wear gowns, gloves, medical mask and eye protection (goggles or face shield).
  • Cleaners in triage, waiting and examination areas should wear gown, heavy duty gloves, medical mask, eye protection (if risk of splash from organic material or chemical), boots or closed work shoes.
• HCWs who develop respiratory symptoms (e.g., cough, shortness of breath) should stay home and not perform triage or any other duties at the healthcare facility.
• Ensure that environmental cleaning and disinfection procedures 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 periods of community transmission

• Begin or reinforce existing alternatives to face-to-face triage and visits such as telemedicine³.
• Designate an area near the facility (e.g., an ancillary building or temporary structure) or identify a location in the area to be a “respiratory virus evaluation center” where patients with fever or respiratory symptoms can seek evaluation and care.
• Expand hours of operation, if possible, to limit crowding at triage during peak hours.
• Cancel non-urgent outpatient visits to ensure enough HCWs are available to provide support for COVID-19 clinical care, including triage services. Critical or urgent outpatient visits (e.g. infant vaccination or prenatal checkup for high-risk pregnancy) should continue, however, facilities should ensure separate/dedicated entry for patients coming for critical outpatient visits to not place them at risk of COVID-19.
• Consider postponing or cancelling elective procedures and surgeries depending on the local 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 control during health care when novel coronavirus (nCoV) 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: opportunities and developments in Member States: report on the second global survey on eHealth. Global Observatory for eHealth Series, 2, World Health Organization. 2009.
4. World Health Organization. Global Surveillance for human infection with coronavirus disease (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 agents. J Hosp Infect. 2020 Mar;104(3):246-251. doi: 10.1016/j.jhin.2020.01.022.

7. Acknowledgements

CDC would like 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 their valuable contributions to this SOP.

Appendix 1: Visual Alert to Direct Patient with Respiratory Symptoms

Source: https://tools.cdc.gov/api/embed/downloader/download.asp?m=403372&c=405817