ACEM - Triage and Reception of Patients

We align with:

Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. https://doi.org/10.17226/18338. [Link]
European Centre for Disease Prevention and Control, Technical report: Pandemic influenza preparedness in the EU, 2007. [Link]
Hick, J. L., D. Hanfling, M. K. Wynia, and A. T. Pavia. 2020. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. NAM Perspectives. Discussion paper. National Academy of Medicine. Washington, DC. https://doi.org/10.31478/202003b. [Link]
Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. https://doi.org/10.17226/12749. [Link]
The Australian Health Sector Emergency Response Plan for Novel Coronavirus COVID-19. [Link]
Emergency Response Plan for Communicable Disease Incidents of National Significance: National Arrangements. [Link]
New Zealand Pandemic Action Plan. [Link]
Communicable Diseases Network Australia (CDNA) National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia. [Link]

Given the highly infectious nature of COVID-19 it is imperative to ensure transmission of the virus is reduced as much as possible. Emergency departments (EDs) are the first point of contact for many patients with suspected COVID-19 symptoms or disease.

During a pandemic, principles of triage include a triage system that:

Is simple and easy to use and facilitates rapid processing of patients presenting to the ED.
Will identify and isolate those at increased risk of disease, thus reducing potential for transmission to other patients and health staff.
Can be easily taught and reliably applied by credentialed staff.

A pandemic is not a surge over a few days like a Mass Casualty Incident (e.g. plane crash) but an initial slow increase, then an exponential increase. Triage processes will thus need to be fluid and adaptable. There should be agreed trigger points when your ED will switch to disaster triage, and the Hospital Incident Management Team should have predetermined responses to a graded whole-of-hospital response when this occurs (also see recommendations in the Pandemic planning section).

Planning should include discussions regarding funding implications of changing from Australasian Triage Scale (usual) triage to disaster triage, and the development of hospital electronic information systems that are compatible with this change.

A ‘whole of health service’ approach, balancing capacity and safety, will be necessary to identify optimal ED configuration and direct streaming to inpatient areas. ED zoning will allow for the creation of high risk and lower risk areas within ED, according to risk factors and clinical features identified during patient screening (also see ED design layout section).

Triaging – practical considerations
We recommend:
1. Staff comply with personal and protective equipment (PPE) recommendations according to current published guidance from relevant health jurisdictions (see Personal and Protective Equipment section).
2. Staff must be fully attired in appropriate level PPE prior to triaging any patient.
3. Well persons presenting from the community due to concern regarding COVID-19 risk, or requesting COVID-19 screening, should ideally be referred to community-based testing (also see Assessment Clinic section).
4. Triaging for ambulatory patients and those arriving by ambulance will follow the same process.
5. Identification of patient cohorts should occur consistent with the COVID-19 risk groups identified by features and testing as illustrated below (Figures 5 and 6).
6. Geographical re-configuration of EDs will be required to safely accommodate arriving patients according to both their COVID-19 risk status, and clinical priority:
  - The movement of people shall follow the principle of establishing a contaminated zone, a potentially contaminated zone and a clean zone which are clearly demarcated, with buffer zones between the zones.
  - Planning may include capacity to immediately stream higher dependency and critical COVID-19 high risk patients to negative pressure rooms within the hospital, with a COVID rapid response call to the facility Critical Care/Intubation team.
  - Streaming out of the ED for specific patient groups who are clinically stable and have no or low identified COVID-19 risk may also be a component of the ED zone planning.
  - Consideration of transport of patients and equipment from each zone should be part of the design.
  - Procedures for clinical staff to don and doff their protective equipment should be standardised and observed.
  - Flowcharts of different zones, donning and doffing areas, and staff walking routes should be displayed and communicated widely.
  - A front of house pre-examination and triage area may be separately established to perform preliminary screening of patients, depending on the volume of attendances to the ED; otherwise, this function may be performed by the existing Triage. Provision to upscale to a separate front of house screening triage station should be planned and trigger points communicated.
  - Flow of patients to zones within the ED will align with assessment of their likely COVID-19 status and clinical presentation, for example Australasian Triage Scale category, until a trigger point to commence disaster triage has been reached (see below).
7. It is noted that with significant progression of the pandemic and high community transmission, all arriving patients will need to be considered to be at risk for COVID-19.
Figure 5. Adapted from What US Hospitals Should Do Now to Prepare for a COVID-19 Pandemic
Note: see [Link] for more details

The triage process is based on COVID-19 infectious risk and clinical priority.

Figure 6. COVID-19 infectious risk and clinical priority.
The role of disaster triage
A disaster from a Pandemic is different from a Mass Casualty Incident (MCI) where an event results in a number of casualties vastly exceeding local resources and capabilities in a short period of time.

A pandemic follows a bell curve, reaching the peak number of patients halfway through (usually in 5 to 6 weeks), whereas an MCI tapers off quickly. In terms of resource allocation, an ED needs to prepare differently in a Pandemic. This involves an increasing response over a few weeks, keeping in mind that staff and resources may become less available as the situation continues.

A schema for thinking about ramping up to disaster triage and response is illustrated below in Figure 7:

Figure 7. Adapted from: Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. https://doi.org/10.17226/18338.[Link]

This requires an ED and whole of health service plan to identify capacity at each stage and trigger points for moving to the next. For example, stages of disaster triage activation may include consideration of:
- Conventional service levels, where a service has suitable space, staff, resources sufficient to deliver usual care;
- Contingency service levels where a service has adapted by enhancing space, staff and resources and engaging with other hospital and community services to enhance capacity.
- Crisis service levels where enhanced resources are overwhelmed and agreed crisis standards of care must be applied. This will necessitate the commencement of Disaster Triage.
Stages in disaster/crisis care

When the hospital is overwhelmed and reverts to Disaster Triage, then all models of care previously described are subsumed in favour of Disaster Triage and crisis care models.
How to do disaster triage
We recommend following the Major Incident Medical Management System (MIMMS) system of triage which is that of Sieve and Sort. It measures various physiological parameters that identify the priorities for treatment. For details on this please see [Link].

We recommend:
1. Triage during the COVID-19 pandemic should adopt the key principles of:
  - Reducing the transmission of infection to healthcare staff and other patients.
  - Ensuring adaptability in response, and anticipate the need to transition to disaster triage.
  - Simplicity and reproducibility to facilitate training.
2. Alignment of triage with geographical re-configuration of EDs (zoning) to safely accommodate arriving patients according to both their COVID-19 risk status, and clinical priority.
3. EDs and Health Services should plan for and identify disaster phases and responses to surges in ED and facility demand, such that appropriate care is provided to patients for as long as possible. Implementation of disaster triage and crisis care models should align with the principles of decision making described in accepted ethical frameworks (see Ethics in ED Decision Making section).
We do not recommend:
1. Ramping of ambulance patients, or queuing of waiting patients at close proximity to each other, within any area of the ED. Priority should be given to enhanced patient flow out of the ED, or bypassing ED, to reduce the risk of crowding and the spread of infection.
We advocate for:
1. Early consideration of Triage Models of Care to divide your ED into infectious/noninfectious areas (or COVID-19 and non COVID-19 zones).
2. Mobilisation of resources to staff these areas, with consideration of staff that are older than 60 and those with pre-existing medical conditions that puts them at higher risk of acquiring COVID-19 infection and developing respiratory and other complications. (Guan, W, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 28 Feb 2020. DOI: 10.1056/NEJMoa2002032. [Link]) Special consideration should be given to pregnant staff as recommended by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)’s statement, ‘A message for pregnant women and their families’, 29 March 2020. [Link]
3. Ensuring higher risk and lower risk zones within the ED have separate access to radiology/pathology, clearly defined entry and exit paths for safe transfer to inpatient areas, and for discharge home, to minimise risk to staff and patients.
References
The following resources were used in the preparation of this section:
- AHRQ (Agency for Healthcare Research and Quality). 2005. Altered standards of care in mass casualty events. Prepared by Health Systems Research, Inc. under contract no. 290- 04-0010. AHRQ Publication No. 05-0043. Rockville, MD: AHRQ. [Link]
Section disclaimer

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.
Resources

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.

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