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

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 as more information becomes available.

1.1 What is triage

“The sorting out and classificationexternal icon of patientsexternal icon or casualties to determine priority of need and proper place of treatmentexternal icon.”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 already in place in healthcare facilities (e.g. Manchester triage system or equivalent²) to categorize patients into different urgency categories.

1.2 COVID-19 transmission

The main route of transmission of COVID-19 is through respiratory droplets generated when an infected person coughs or sneezes.  Any person who is in close contact with someone who has respiratory symptoms (e.g., sneezing, coughing, etc.) is at risk of being exposed to potentially infective respiratory droplets.³  Droplets may also land on surfaces where the virus could remain viable for several hours to days. Transmission can occur from hands contacting contaminated surfaces and then coming into contact with the person’s mucosa such as nose, mouth and eyes.

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

• Inform healthcare providers if they are seeking care for COVID-19 symptoms (e.g. fever, cough, myalgia, fatigue, headache, shortness of breath, loss of smell or taste, sore throat or other) ⁴ by calling ahead of time.
• Wear a medical mask (e.g., surgical or procedure masks) and, if not available, wear a cloth or fabric mask during transport and while at triage in the healthcare facility.⁵
• Notify triage registration desk about symptoms suggestive of COVID-19 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 according to WHO guidance (CDC recommendation is at least 6 feet or 1.8 meters) 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 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 and the signs and symptoms of COVID-19.
• 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.⁶ However, patients with any emergency warning signs such as trouble breathing, new confusion, persistent pain or pressure in the chest, or inability to wake or stay awake should seek medical care immediately.

Set up and equip triage

• Limit point of entry to the health facility.
• Have clear signs at the entrance pdf icon[97 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 recommendationexternal icon (CDC recommends 6 feet or 1.8 meters) 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 pdf icon[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 definition^4,7. 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 given the global pandemic.

Download a poster directing patients with symptoms of COVID-19 to the registration desk. pdf icon[97 KB, 1 page]

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 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 based on WHO recommendationsexternal icon (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.⁴
• 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.
• If medical masks 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 COVID-19 waiting area. A homemade cloth mask can also be used as source control, if the patient has one. 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 itemsexternal icon.
• 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 a patient or a parent). Anyone in the separate waiting area for suspected COVID-19 should wear a medical mask. If medical mask is not available, wear a cloth mask or use multiple layers paper tissues or other fabrics such as T-shirts or scarfs to cover their nose and mouth.
• 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 pdf icon[411 KB, 1 page] or 70% alcohol for surfaces that do not tolerate chlorine. For large blood and body fluid spills, 0.5% (5000ppm) chlorine pdf icon[1 MB, 1 page] is recommended.⁸

*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).   

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 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.
  • Follow appropriate PPE donning and doffing steps pdf icon[2.9 MB, 3 pages].
  • Perform frequent hand hygiene 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 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 recommendationsexternal icon (CDC recommends 6 feet or 1.8 meters). 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 medical masks or taking temperatures with infrared thermometers as long as a distance of at least one meter based on WHO recommendationsexternal icon (CDC recommends two meters)  can be safely maintained.
    • When physical distance is NOT feasible and yet NO direct contact with patients occurs, use a medical mask and eye protection (face shield or goggles).
  • 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, 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.
• Ensure that environmental cleaning and disinfection procedures are followed consistently and correctlyexternal icon.

5. Additional considerations for triage during periods of community transmission

• Begin or reinforce existing alternatives to face-to-face triage and visits such as telemedicine.⁶
• 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.

6. References

1. Medical Dictionaryexternal icon. Accessed on March 18.2020
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. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected or confirmedexternal icon. Accessed on July 27, 2020
4. World Health Organization. Clinical management of COVID-19external icon. Accessed on July 29, 2020
5. World Health Organization. Advice on the use of masks in the context of COVID-19external icon. Accessed on July 29, 2020
6. 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 pdf icon[3.5 MB, 96 pages]external icon.
7. World Health Organization. COVID-19 Case Definitionexternal icon. Accessed on August 21, 2020
8. 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.