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

icaro.bski@haoc.com.br

scih@haoc.com.br