Standard Operating Procedure (SOP) for Triage of Suspected COVID-19 Patients

Updates as of July 2, 2024

• Updated recommendations to align with current guidance
• Updated the list of references

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).

What is triage?

Triage is "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. Infectious 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.

Minimize risk of infection among patients and healthcare workers

Set up and equip triage

• Have clear signs at the entrance of the facility directing patients with COVID-19 symptoms to immediately report to the registration desk in the emergency department or at the unit where they are seeking care (e.g., maternity, pediatric, HIV clinic).
• Ensure availability of medical masks and paper tissues 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.
• 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 when coughing or sneezing and disposal of contaminated items in trash cans.
• Train administrative personnel working in the reception area on how to perform hand hygiene and maintain appropriate distance, and 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. 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 area4 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.5 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.
• 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 waiting area.
• Develop a process to reduce the amount of time patients are in the 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 waiting area should wear a medical mask or a well-fitting form of source control.
• When there is a significant impact of COVID-19 on the health system all persons should wear masks within the health facility5.
• 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). Anyone in the separate waiting area for suspected COVID-19 should wear a medical mask.5
• 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 or 70% alcohol for surfaces that do not tolerate chlorine.6

*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).3

Protect healthcare workers and patients during triage

Healthcare workers should:

• Remain up to date with all recommended COVID-19 vaccine doses per their country immunization policies and continue to follow IPC measures5 described here.
• Adhere to Standard Precautions, which include hand hygiene, selection of PPE based on risk assessment, respiratory hygiene, cleaning and disinfection and injection safety practices.
• Be trained on and familiar with recommended infection prevention and control (IPC) precautions (e.g. appropriate hand hygiene, donning and doffing of PPE) related to COVID-19.
  • Follow appropriate PPE donning and doffing steps.
  • 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.
• Wear appropriate PPE when in contact with suspected or confirmed COVID-19 patients:
  • HCWs conducting physical examination of patients with symptoms suggestive of COVID-19 should wear gowns, gloves, a medical mask, and eye protection (goggles or face shield).
  • In areas of known or suspected community SARS-CoV-2 transmission, all HCWs should wear masks regardless of vaccination status for source control.
  • In triage areas, HCWs 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.
  • Examples of when PPE is not necessary include: 1) HCWs at the registration desk that are asking limited questions based on triage protocol; 2) HCWs providing medical masks or taking temperatures with infrared thermometers as long as a distance of at least one meter based on WHO recommendations can be safely maintained.
• Stay home and not perform triage or any other duties at the healthcare facility and follow the policy on return to work if they develop symptoms suggestive of COVID-19 (e.g., fever, cough, shortness of breath, loss of smell or taste, sore throat).

Facilities administrators should:

• Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly.
• Wear a gown, heavy duty gloves (e.g., thick rubber reusable gloves), a medical mask, eye protection (if risk of splash from organic material or chemical), boots or closed work shoes in triage, waiting and examination areas.

Triage during high-risk situations or periods

• Implement or reinforce existing alternatives to face-to-face triage and visits such as telemedicine.7
• 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 checkups 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.