Post on 08-Aug-2021
Triage of COVID-19 patientsExperience of a center in
BrazilÍcaro Boszczowski
Hospital Alemão Oswaldo Cruz
Hospital das Clínicas, Universidade de São Paulo
• Scenario
• Planning
• Activating
• Adapting
• Lessons learned
Introduction
NO DISCLOSURES
I have no financial relationships with commercial entities producing healthcare related products and/or services
Related to this presentation
Objective
To present the experience of Hospital Alemão Oswaldo Cruz, São Paulo, Brazil, in implementing a triage system to quickly identifying and
allocating patients suspected of COVID-19
The Hospital
Unidade Vergueiro Complexo Hospitalar dos EstivadoresSantos, São Paulo, Brasil
Consolidated figures considering the installed capacity of all units
WHO WE ARE • FIGURES
4,235Active
physicians
805beds
3,011Staff members
+ 136,000 m2
Built area
+
Jan/2020Dec/2019
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 311 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
08/12 First reports
Pneumonia
Wuhan/China 08/01 First WHO alert:
44 cases of “pneumonia
of unknown etiology”
related to seafood Market
in Wuhan/China
30/01 WHO – Declares
emergency of international
concern
30/12 Report to
WHO
Cluster of
“pneumonia of
unknown
etiology”
21/01 WHO – report
Moderate risk
28/01 WHO raises risk to
“High”
PREPARATION – evolving steps
Ministry ofHealth
Activates COE
First meeting to plan the response
ANDFirst hospital
informative report
Questions that guided the triage planning
• How to promptly identify symptomatic patients and properly separatethem from patients at risk of acquiring the virus while cared in thehospital?
• How to protect healthcare workers while caring for patients withCOVID-19?
Preparedness Check lists
Thinking the process of triage
• Signaling the patient flow• Before patient arrival• At patient arrival• After patient arrival
• Safe waiting areas• Information• Structure• Process
• Trainning on infection prevention
• Adequate use of PPE
• Identifying patients at greater risk
Patient
Healthcare facility
Healthcare workers
Preparation
31/01 – Mapping main
facility entrances and
waiting rooms
30/01 – Two symptomatic
travelers from China presented at
ED
29/01 – Operational Workshop with
Emergency Department
31/01 - Established a daily meeting
involving IPC, ED, High leadership and
other invited areas to activate a contigency
plan
Go
vern
me
nt
guid
elin
es
Pre
par
atio
np
has
e
05/02 – Estabishment of CRISIS
GABINET:
DAILY MEETINGS IPC and diferente
areas
WEEKLY MEETINGS all units10/02 – Informative text to patientsconcerningCough etiquette and social distancing
11/02 – Sign installation for patients at all entrances
12/02 – Masks, paper tissues and alcohol based hand-rub available at all entrances
14/02 – Started personnel training in loco focused on ED
Training1. Planning and preparing for COVID-19 – open
session (before social distancing);
2. Dedicated sessions for ED personnel;
3. Scientific meetings• Laboratory testing• Local Health authorities ( Municipal Health
Department)
3. Online trainigns• Donning and doffing• Use of masks• Hand hygiene
4. Facebook – lives and chats
Communication
1. Situation reports;
2. Technical updates (Ministry of Health updates)
3. Evolving plan (contingency)
3. Informative texts for patients (Portuguese, Englishand Mandarin)
4. Informative texts for Healthcare workers
5. Informative texts for administrative personnel
6. Television, internet and other media
Mapping the entrances
Delivering Key messages
• Wash hands or use na alcohol-based hand rub
at hospital entrance
• Pick up a face mask
• Present yourself if respiratory symptoms
• Use paper tissues to cover mouth and nose
• Keep safe distance from others (1m)
Signs at entrance areas of the hospital
External area before entering the facility building
Signs at entrance areas of the hospital
At the entrance hall
ElevatorTotem of
Service menu
Selecting the “coronavirus” button
Fever, cough, short breath and recent travel to China
Preparing the structure
Triage flow chart
Patientidentification
Patientevaluation
High risk/mild symptoms
• CT scan
• Calculate qSOFA• = zero discharge• ≥ 1 admit patient
• Test (influenza and RT-PCR SARS-COV2)
• Other Lab tests at physician discretion
High risk/ severe symptoms
• Admit patient to the Intensive Care Unit
• CT scan after admission
• Other Lab tests at physician discretion
• Inititate oseltamivir and antibiotic (at physiciandiscretion)
• Test (influenza and RT-PCR SARS-COV2)
Low risk/mild symptoms
• Do not demand other laboratory tests
• Calculate qSOFA• = zero discharge• ≥ 1 admit patient
• Test (influenza e RT-PCR SARS-COV2)
• Discharge post test
Low risk/severe symptoms
• Admit at Intensive Care Unit or Ward at physiciandiscretion
• CT scan after admission
• Other Lab tests at physician discretion
• Inititate oseltamivir and antibiotic (at physiciandiscretion)
• Test (influenza and RT-PCR SARS-COV2)
Dedicated flow to CT scan
• Patient waits in the ED
• One equipment dedicated toCOVID patients
• Safety for transportation• Patient with medical mask
• HCW dedicated to the room
Ready for battle?
And then it’s CARNIVAL !!!
Just four days before the first reported case in BRAZIL
Activation
Number of visits to Emergency Department in 2020
Jan/20 Fev/20 Mar/20 Abr/20
Total n of patients in ED 6774 5837 5907 2292
Coronavirus button 0 73 1950 1050
Adaptation
COVID_19 Situation report in Brazil May, 12th 2020
Number of confirmed cases Number of deaths
São Paulo city 30457 2428 (7.9%) Brazil 181000 12635(6.9%)
188974 13749 (7%)
New approaches
• Telemedicine
• Telephone calls before scheduling electivesurgeries and at admission
• Daily screening of HCW at entrance
• Daily negative notification of respiratorysymptoms (patients in non COVID area)
Facilitators
• Crisis committee
• Leadership involvement
• Rapid decision making
• Consistent evaluation of actions
• Comprehensive involvement: supply, marketing, laboratory, engineering, environmentalcleaning, HCW
Barriers
• Fast spread of fake News• internet (social media), whatsapp
• Threat of PPE shortage
• Threat of health system collapse
Take home messages
• Plan with comprehensive participation of strategic areas
• Learn from other’s experience
• Adapt and be ready to change quickly
• Provide a consistent and robust plan of communication and education