key: cord-0835572-pr2md1hg
authors: Anschau, Fernando; Worm, Paulo Valdeci; Kopittke, Luciane; de Mello Villwock, Luis Humberto; Lemos Sartori, Marcos Luiggi; Cardoso do Rosário, Jéferson; Secorun Inácio, José Francisco; Much, Maicon Diogo; Marckmann, Eduardo; Pinheiro, Sandro; Nickenig Vissoci, João Ricardo; de Lara Machado, Wagner; Costa, Dalton Breno; Klug, Daniel; Martin Prestes, Juliane; Hessel, Fabiano
title: Smart Check – COVID‐19 triage system: Evaluation of the impact on the screening time and identification of clinical manifestations of SARS‐CoV‐2 infection in a public health service
date: 2021-07-16
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14610
sha: 112c660521302914e60175a354006b1572a35b6d
doc_id: 835572
cord_uid: pr2md1hg

INTRODUCTION: Most patients with COVID‐19 have mild or moderate manifestations; however, there is a wide spectrum of clinical presentations and even more severe repercussions that require high diagnostic suspicion. Vital sign acquisition and monitoring are crucial for detecting and responding to patients with COVID‐19. OBJECTIVE: Thus, we conducted this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID‐19 and to identify the main initial clinical manifestations in these patients. METHODOLOGY: We assessed triage times before and after the use of Smart Check in 11 466 patients at Hospital Nossa Senhora da Conceição in Porto Alegre, Brazil, from 1 June to 31 July 2020. In this group, we identified 220 patients for the identification of COVID‐19 clinical manifestations in a case–control analysis. RESULTS: Smart Check was able to decrease the triage time by 33 seconds on average (P < .001), with 75% of the exams being performed within 5 minutes, whereas with the usual protocol these steps were performed within 6 minutes. A range of clinical presentations made up the COVID‐19 initial manifestations. Those with the highest frequency were dry cough (46.4%), fever (41.3%), dyspnoea (35.8%), and headache (31.8%). Loss of appetite was the manifestation that had a statistically significant association with the SARS‐CoV‐2 presence (univariate analysis). When analysed together, loss of appetite associated with dyspnoea and/or ageusia and/or fever was related to the diagnosis of COVID‐19. CONCLUSIONS: Smart Check, a simple clinical evaluation tool, along with the targeted use of rapid PCR testing, can optimise triage time for patients with and without COVID‐19. In triage centres, a number of initial signs and symptoms should be cause for SARS‐CoV‐2 infection suspicion, in particular the association of respiratory, neurological, and gastrointestinal manifestations.

A new coronavirus (CoV) with a high virulence and capable of infecting humans (HCoV) is currently holding much of the world's population hostage. This virus, known as coronavirus 2, responsible for the severe acute respiratory syndrome (SARS-CoV-2) and coronavirus 2019 (COVID-19) disease, emerged in late 2019 in China and is currently affecting the population in more than 210 countries and territories worldwide. On 30 January 2020, the WHO declared it a Public Health Emergency of International Concern and on 11 April 2020, it was declared a pandemic. 1 At the time of this article's writing, the WHO estimates that COVID-19 has been diagnosed in 108 579 352 people from 210 countries worldwide, causing about 2 396 408 deaths. 2 In Brazil, there have been more than 9.8 million patients and about 240 000 deaths. 2 SARS-CoV-2 belongs to a family of viruses that can cause various symptoms, such as pneumonia, fever, difficulty breathing and pneumonitis. 3 Clinical manifestations include fever, cough, dyspnoea, myalgia, fatigue, headache, diarrhoea, hemoptysis, anosmia and augesia. 4, 5 Most patients with COVID-19 have mild to moderate symptoms, but approximately 15% may progress to critical pneumonia and eventually develop severe acute respiratory syndrome (SARS), septic shock, multiple organ failure and death. 4 Once the infection sets in, it requires a high degree of suspicion for a correct diagnosis and the institution of appropriate therapeutic and restrictive measures because of the enormous manifestations spectrum.

Vital sign acquisition and monitoring are crucial for detecting and responding to deteriorating patients; however, it is known that during routine vital sign acquisition and recording, many of the vital sign records in medical records are incomplete or inconsistent, which can compromise patient safety. 6 Thus, we propose this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID-19 and identify its main clinical manifestations.

We performed data collection of the time of risk classification and signs and symptoms of suspected COVID-19 patients at the COVID-19 Triage Center of the Hospital Nossa Senhora da Conceição (HNSC) in Porto Alegre, in the southern region of Brazil, from 1 June 1 to 31 July 2020. HNSC is a public health service of reference to care for COVID-19. This triage centre has a reception and waiting area, a registration and triage area, two boxes for exam collection, three consulting rooms, a stabilisation room, and a specific environment for the professionals' paramentation and deparamentation. It is open daily, from 8 AM to 10 PM, with a team of one administrative assistant, three nurses, three doctors, and four nursing technicians. Nursing technicians were responsible for the classification-COVID-19 screening. In addition, it has three professional hygienists strategically distributed to keep the environment constantly disinfected. The COVID-19 triage centre sees patients with influenza syndrome and identifies patients with potential symptoms for COVID-19, referring those with severity signs to the HNSC emergency room. The time to check vital signs (temperature, blood pressure, blood saturation, heart and respiratory rates) was considered as a classification time ( Table 1 ). The clinical manifestations were collected in anamnesis and categorised as listed in Table 2 .

In the period from 1 July to 31 July 2020, we introduced the Smart Check tool (multiparametric monitor from the company Toth Life Care®; certificate of conformity TÜV 17.1492 dated 24

April 2018), a compact multiparametric vital signs monitor, into that triage centre's care routine. Through Smart Check there is the possibility to quickly acquire vital signs (systolic, diastolic, and noninvasive mean arterial pressure and pulse rate, functional oxygen saturation, body temperature, blood glucose level) and, in triage mode, store and display the history of the triages performed. This triage tool communicates with external devices via Bluetooth, it has a bar code reader that allows quick identification of patients wearing identification bracelets, and ethernet and wireless communication with the transmission in HL7 protocol for integration with Hospital Information Systems. In this study, we used accessory Risk Classification software (SMART RISK®) for Emergency management.

To determine the impact of Smart Check on COVID-19 triage time, we conducted a before-and-after type study (n = 11 466).

After the screening performed, the patients were submitted to medical evaluation when some, clinically stable and in good health, were instructed and maintained specific care, with no indication to perform the RT-PCR test. Thus, not all 11 466 screened patients underwent RT-PCR examinations.

It is important to be assertive and quick in identifying patients of COVID-19. The main signs and symptoms related to SARS-CoV-2 infection are referenced in the literature and exhibit a wide variety of clinical presentations.

It is important to be assertive and quick in identifying pa- Considering an expected sensitivity of 95%, expected specificity of 80%, with a margin of error of 10% and a prevalence of 5.8% of COVID-19 in our population, our sample would be estimated at 210 individuals.

We expressed continuous variables as medians and interquartile ranges or simple intervals, as appropriate. We summarised categorical variables as counts and percentages, and we calculated associations with Student's t test, chi-square and Mann-Whitney tests. We made no imputation for missing data. We performed all analyses using SPSS 22.0. 

One strategy for fighting the COVID-19 pandemic was rapid diagnosis and care in these specific environments, with segregation of patients with the disease's most severe and characteristic symptoms.

Even in such environments, patients who seek care for suspected infection may be exposed to the infection itself if they stay longer than 

We demonstrated how a simple clinical evaluation tool-the Smart Check-along with the targeted use of rapid PCR testing, can opti- 

Data available on request from the authors.

Fernando Anschau https://orcid.org/0000-0002-2657-5406

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