Important update: Healthcare facilities
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UPDATE
Given new evidence on the B.1.617.2 (Delta) variant, CDC has updated the guidance for fully vaccinated people. CDC recommends universal indoor masking for all teachers, staff, students, and visitors to K-12 schools, regardless of vaccination status. Children should return to full-time in-person learning in the fall with layered prevention strategies in place.
UPDATE
The White House announced that vaccines will be required for international travelers coming into the United States, with an effective date of November 8, 2021. For purposes of entry into the United States, vaccines accepted will include FDA approved or authorized and WHO Emergency Use Listing vaccines. More information is available here.
UPDATE
Travel requirements to enter the United States are changing, starting November 8, 2021. More information is available here.

Standard Operating Procedure (SOP) for Triage of Suspected COVID-19 Patients in non-US Healthcare Settings: Early Identification and Prevention of Transmission during Triage

Standard Operating Procedure (SOP) for Triage of Suspected COVID-19 Patients in non-US Healthcare Settings: Early Identification and Prevention of Transmission during Triage
Updated Oct. 18, 2021

Summary of Recent Changes

  • Minor revisions to improve clarity and flow of guidance

Key Points:

  1. Early identification and separation of suspected COVID-19 patients at triage is important to prevent transmission in healthcare facilities
  2. Healthcare facility administrators need to provide public and patients with information on COVID-19 prevention measures before and upon arrival at the healthcare facility
  3. Healthcare facility administrators should ensure that physical infrastructure and supplies needed for triage are in place
  4. Clear communication and training of healthcare facility staff is essential to ensure triage process is implemented correctly to prevent COVID-19 transmission among patients and healthcare workers

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 COVID-19 data and experience with other respiratory viruses and will be updated further more information becomes available.

What is triage

“The sorting out and classification of patients or casualties to determine priority of need and proper place of treatment.”1 During infectious disease outbreaks, triage is particularly important to separate patients likely to be infected with the pathogen of concern. This triage SOP is developed in the context of the COVID-19 pandemic and does not replace any routine clinical triage SOPs in place in healthcare facilities (e.g. Manchester triage system or equivalent2) to categorize patients into different urgency categories.

COVID-19 transmission

COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. These droplets and particles can be breathed in by other people or land on their eyes, noses, or mouth. In some circumstances, they may contaminate surfaces they touch. People who are closer to the infected person are most likely to get infected. For more information on SARSCoV-2 transmission refer to Scientific Brief: SARS-CoV-2 Transmission.

2. 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 COVID-19 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 with information on the signs and symptoms of COVID-193.
    • Importance of notifying healthcare providers if they are seeking care due to COVID-19 symptoms before arriving at the facility.
    • Signs and symptoms of severe COVID-19 disease such as trouble breathing, new confusion, persistent pain or pressure in the chest, or inability to wake or stay awake
    • Preventive measures, such as mask use4, social distancing, respiratory etiquette, and hand hygiene before and upon arrival to a healthcare facility
  • Healthcare facilities, in conjunction with national authorities, should consider telemedicine (e.g., telephone, audio-video calls, or secure messaging) to provide clinical support without direct contact with the patient.5

Set up and equip triage

  • Limit point of entry to the health facility.
  • Have clear signs at the entrance [89 KB, 1 Page] of the facility directing patients with COVID-19 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). Facilities should consider having a separate registration desk for patients coming in with COVID-19 symptoms, especially at the emergency departments, and clear signs at the entrance directing patients to the designated registration desk.
  • Ensure availability of medical masks 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) and maintain a distance of at least one meter based on WHO recommendation (CDC recommends 6 feet or 1.8 meters) to limit close contact between registration desk personnel and potentially infectious patients.6
  • Ensure availability of hand hygiene stations (e.g., alcohol-based hand rub 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, cough etiquette and social distancing. This includes how to cover nose and mouth [322 KB, 1 Page] when coughing or sneezing and disposal of contaminated items in trash cans.
  • Assign dedicated clinical staff (e.g. physicians or nurses) for physical evaluation of patients presenting with COVID-19 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 area on how to perform hand hygiene, maintain appropriate distance, and on how to advise patients on the proper use of medical masks, 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 definition3,7. Algorithms should be adjusted based on settings and epidemiologic considerations in each country. HCWs should be encouraged to have a high level of clinical suspicion of COVID-19 until community transmission is low.

Set up a separate 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 area8 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 based on WHO recommendations (CDC recommends 6 feet or 1.8 meters). The waiting areas should have dedicated toilets and hand hygiene stations. Patients who are suspected to have COVID-19 should not be mixed with COVID-19 confirmed patients in isolation areas.3
  • Post clear signs informing patients of the location of waiting areas for suspected COVID-19. Train the registration desk staff to direct patients immediately to these areas after registration.
  • Provide paper tissues, alcohol-based hand rub, and trash bins with lids for the separate COVID-19 waiting area.
  • Develop a process to reduce the amount of time patients are in the COVID-19 waiting area, which may include:
    • Allocation of additional staff to triage patients suspected of 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 where social distance can be maintained and they can be easily notified by phone or other remote methods when it is their turn to be evaluated.

Triage process

  • A medical mask* 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 separate COVID-19 waiting area should wear a medical mask or a well-fitting form of source control.
  • In areas of known or suspected community or cluster SARS-CoV-2 transmission, all persons should wear masks within the health facility4.
  • If medical masks are not available, provide an option that is equivalent to what is recommended for people in the community in the country. For example, a cloth mask can be used as source control if medical mask is not available. Exercise caution as these items will become contaminated and can serve as a source of transmission to other patients or family members. WHO’s guidance should be followed by patients and family members to clean these items.
  • Use a standardized triage algorithm to immediately isolate/separate patients at high risk** for having COVID-19 in single-person rooms with doors closed or designated COVID-19 waiting areas.
  • Limit the number of accompanying family members in the waiting area for suspected COVID-19 patients (do not allow children aged <18 years unless they are patients or a patient’s parent) 0.5% (5000ppm) chlorine [1.03 MB, 1 Page]. Anyone in the separate waiting area for suspected COVID-19 should wear a medical mask, and if not available, a cloth or fabric mask4.
  • Triage area, including a separate waiting area for suspected COVID-19, should be cleaned at least twice a day with a focus on frequently touched surfaces. Disinfection can be done with 0.1% (1000ppm) chlorine [412 KB, 1 Page] or 70% alcohol for surfaces that do not tolerate chlorine. For large blood and body fluid spills, 0.5% (5000ppm) chlorine [1.03 MB, 1 Page] is recommended.9

*Medical masks are defined as surgical or procedure masks that are flat or pleated. Their performance characteristics are tested according to a set of standardized test methods (ASTM F2100, EN 14683, or equivalent)4

**defined as patients at high risk for having COVID-19 based on clinical and epidemiologic criteria (e.g., travel history or exposure to someone with confirmed or suspected COVID-19). Definition may change depending on where countries or regions within countries are in the stage of outbreak (e.g. no or limited vs. widespread community transmission).   

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

  • HCW should get vaccinated and continue to follow IPC measures6 described here.
  • All HCWs should adhere to Standard Precautions, which include hand hygiene, selection of PPE based on risk assessment, respiratory hygiene, cleaning and disinfection and injection safety practices.
  • All HCWs should be trained on and familiar with infection prevention and control (IPC) precautions (e.g. contact and droplet precautions, appropriate hand hygiene, donning and doffing of PPE) related to COVID-19.
  • HCWs who come in contact with suspected or confirmed COVID-19 patients should wear appropriate PPE:
    • HCWs in triage areas 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 based on WHO recommendations (CDC recommends 6 feet or 1.8 meters). However, in areas of known or suspected community SARS-CoV-2 transmission, all HCWs should wear masks regardless of vaccination status for source control.
      Examples of when PPE is not necessary:
      • 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 medical masks or taking temperatures with infrared thermometers as long as a distance of at least one meter based on WHO recommendations (CDC recommends 6 feet or 1.8 meters) can be safely maintained.
    • HCWs conducing physical examination of patients with symptoms suggestive of COVID-19 should wear gowns, gloves, a medical mask and eye protection (goggles or face shield).
    • Cleaners in triage, waiting and examination areas should wear a gown, heavy duty gloves (e.g., tick rubber reusable gloves), a medical mask, eye protection (if risk of splash from organic material or chemical), boots or closed work shoes.
  • HCWs who develop symptoms suggestive of COVID-19 (e.g., fever, cough, shortness of breath, loss of smell or taste, sore throat) should stay home and not perform triage or any other duties at the healthcare facility and follow the policy on return to work.
  • Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.

4. Additional considerations for triage during periods of community transmission

  • Implement or reinforce existing alternatives to face-to-face triage and visits such as telemedicine.5
  • Designate an area near the facility (e.g., an ancillary building or temporary structure) or identify a location in the area to be a “COVID-19 evaluation center” where patients with symptoms of COVID-19 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.

5. References

  1. Medical Dictionary. Accessed on May 18.2021
  2. Zachariasse JM, Seiger N, Rood PP, et al. Validity of the Manchester Triage System in emergency care: A prospective observational study. PLoS One. 2017;12(2):e0170811. Published 2017 Feb 2. doi:10.1371/journal.pone.0170811
  3. World Health Organization. Clinical management of COVID-19. Accessed on May 18, 2021
  4. World Health Organization. Mask use in the context of COVID-19. Accessed on May 18, 2020
  5. World Health Organization. Telemedicine: Opportunities and Developments in Member States: Report on the Second Global Survey on eHealth 2009 (Global Observatory for eHealth Series, Volume 2) – PMC (nih.gov).
  6. World Health Organization. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected or confirmed. Accessed on Aug 25, 2021
  7. World Health Organization. COVID-19 Case Definition. Accessed on August 21, 2020
  8. WHO. Roadmap to improve and ensure good indoor ventilation in the context of COVID-19: https://www.who.int/publications/i/item/9789240021280
  9. 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.