key: cord-1012156-wdmr95g9 authors: Chang, Julia Chia-Yu; Chen, You-Hsu; Lin, Meng-Chen; Li, Yi-Jing; Hsu, Teh-Fu; Huang, Hsien-Hao; Yen, David Hung-Tsang title: Emergency department response to coronavirus disease 2019 outbreak with a fever screening station and “graded approach” for isolation and testing date: 2020-09-04 journal: J Chin Med Assoc DOI: 10.1097/jcma.0000000000000420 sha: 0daa306805731e68ddd3b590e55b70a81f7ab323 doc_id: 1012156 cord_uid: wdmr95g9 BACKGROUND: Ever since coronavirus disease 2019 (COVID-19) emerged in Wuhan, China, in December 2019, it has had a devastating effect on the world through exponential case growth and death tolls in at least 146 countries. Rapid response and timely modifications in the emergency department (ED) for infection control are paramount to maintaining basic medical services and preventing the spread of COVID-19. This study presents the unique measure of combining a fever screening station (FSS) and graded approach to isolation and testing in a Taiwanese medical center. METHODS: An FSS was immediately set up outside the ED on January 27, 2019. A graded approach was adopted to stratify patients into “high risk,” “intermediate risk,” and “undetermined risk” for both isolation and testing. RESULTS: A total of 3755 patients were screened at the FSS, with 80.3% visiting the ED from home, 70.9% having no travel history, 21.4% having traveled to Asia, and 10.0% of TVGH staff. Further, 54.9% had fever, 35.5% had respiratory symptoms, 3.2% had gastrointestinal symptoms, 0.6% experienced loss of smell, and 3.1% had no symptoms; 81.3% were discharged, 18.6% admitted, and 0.1% died. About 1.9% were admitted to the intensive care unit, 10.3% to the general ward, and 6.4% were isolated. Two patients tested positive for COVID-19 (0.1%) and 127 (3.4%) tested positive for atypical infection; 1471 patients were tested for COVID-19; 583 were stratified as high-risk, 781 as intermediate-risk, and 107 as undetermined-risk patients. CONCLUSION: Rapid response for infection control is a paramount in the ED to confront the COVID-19 outbreak. The FFS helped divide the flow of high- and intermediate-risk patients; it also decreased the ED workload during a surge of febrile patients. A graded approach to testing uses risk stratification to prevent nosocomial infection of asymptomatic patients. A graded approach to isolation enables efficient allocation of scarce medical resources according to risk stratification. infection within the ED in a tertiary medical center in Taiwan, with the purpose of early triage, isolation, and detection of COVID-19 patients. We conducted a retrospective study in the ED of a tertiary medical center. This project was reviewed and approved by Institutional Research Board, which waived the need for patient consent (No. 2020-06-011BC). The Taipei Veterans General Hospital (TVGH) is a 2900-bed university-affiliated leading medical center in Taiwan. It closely follows the updated recommendations for the diagnosis of COVID-19 released by the National Health Command Center (NHCC). The NHCC, with the Taiwan Center of Disease Control (CDC) as its base, was established in 2004 in response to the global epidemic of severe acute respiratory syndrome, which relentlessly tested Taiwan's capability of public health emergency management in 2003. Given the narrow window of opportunity to prepare for a surge in COVID-19 cases, an FSS was immediately set up outside the ED in TVGH on January 27, 2019. FSS serves to screen patients with fever, relevant TOCC, and high potential for COVID-19 infection, who are denied entry into the ED. Fever surveillance is conducted using infrared thermal-imaging cameras and forehead thermometers. The study included patients screened at the FSS from January 27, 2020, to April 30, 2020. Missing or incomplete data were excluded. Questionnaires on TOCC in accordance with the updated diagnostic criteria were printed and distributed to each patient to fill out before ED entry. A "graded approach" was adapted to stratify patients for both isolation and testing. The reporting criteria of COVID-19 in Taiwan included clinical, epidemiologic, and laboratory criteria. 6 A patient who has one clinical and one epidemiologic/ laboratory criteria fulfills the reporting criteria. On the basis of recommendations from the NHCC and Taiwan CDC, hospitals in Taiwan must stratify patients into three categories: (1) high risk (2) , intermediate risk, and (3) undetermined risk. 6 A graded approach for isolation helps identify high-risk patients who are denied entry into the ED and immediately ushered into a negative-pressure isolation area (higher-level isolation) from an exterior route while waiting to be seen by an EP. Patients with intermediate risk are also denied entry into the ED and ushered into a non-negative pressure isolation area (lowerlevel isolation) from an exterior route. Patients at the undetermined risk without relevant TOCC who do not fit the NHCC case definition are allowed entry into the ED. Graded approach for testing: high-risk and intermediate-risk patients who fit the NHCC case definition are tested and identified as high-risk and intermediate-risk patients accordingly. High-risk patients require two negative COVID-19 test results before being released from isolation for admission. Intermediaterisk patients require one negative test result. Undetermined-risk patients have low risk of infection but are tested before the admission in order to avoid nosocomial infection; these patients are temporarily isolated in the non-negative pressure isolation area while waiting for their COVID-19 results. If one negative COVID-19 test result is obtained, undetermined-risk patients are transferred to a regular observational unit in the ED. Data are expressed as mean ± SD for continuous variables and number (%) for categorical variables. Data distribution was assessed by the Kolmogorov-Smirnov test. Comparisons of numerical variables were performed using an unpaired t test (parametric data) or Mann-Whitney U test (nonparametric data). One-way analysis of variance followed by Turkey multiple range exact test was performed appropriately for statistical analysis between the groups. A p < 0.05 was considered statistically significant. Table 1 shows the demographics of 3755 patients screened at the FSS; the average age was 43.9 ± 21.2 years. While 62.7% had a respiratory system diagnosis, 21.9% had fever of unknown origin (FUO), 5.7% had digestive system disorders, and 2.3% had genitourinary system disorders. Over 81.3% were discharged, 18.6% were admitted, and 0.1% died. About 1.9% were admitted to the intensive care unit (ICU), 10.3% to the general ward, and 6.4% were placed under isolation. Given that an outbreak such as the COVID-19 is likely to disrupt the usual ED functioning and lead to clinical challenges, modifications in the ED such as restricting hospital visitors 7 were immediately implemented at the TVGH. The FSS functions as an independent outpatient clinic with the capacity to carry out blood work, radiographic tests, and discharge febrile patients without ED entry. Data were presented as mean ± standard deviation or n (%). One-way ANOVA followed by Turkey post-hoc test. in treating acute critical patients and emergency cases without compromise. FSS is also effective in preventing nosocomial infection by dividing the flow of walk-in patients at the ED door. A graded approach to isolation directs high-risk patients to negative-pressure isolation area (high level) and intermediaterisk patients to the non-negative pressure area (low level), to ensure efficient allocation of medical resources. The arrangement of isolation areas (red zone) and clean area (green zone) should be individualized according to each hospital's volume and capacity. The demarcation and distribution of these zones should be dynamically adjusted and expanded accordingly. 10 The capacity of the negative-pressure isolation area at TVGH allows only a maximum of three high-risk patients, while the non-negative-pressure isolation area allows six intermediaterisk and undetermined-risk patients. In preparation for a massive increase in patient volume from a community or nosocomial infection, TVGH is prepared to set up make-shift tents outside the ED, serving as new isolation areas. Hence, the objective of a graded approach to isolation, during the early phase of the outbreak, is to reserve high-level facility (negative-pressure) only for high-risk patients and low-level facility (non-negative-pressure) for low-risk patients to efficiently align scarce resources. A graded approach to testing allows physicians to test not only patients at high or intermediate risk but also patients at low risk or undetermined risk who, not fitting the CDC case definition, would not otherwise be tested. A majority of COVID-19 patients present with mild respiratory tract symptoms and some may have no symptoms at all. [3] [4] [5] The common fear of EPs during an outbreak is to forgo testing of patients awaiting admission or surgery who turn out to be positive for COVID-19 only after admission, for which EPs would have a strong sense of professional responsibility. Not to mention, a nosocomial infection would potentially collapse the healthcare service within the hospital. Hence, the allowance to test patients at the underdetermined risk enables EPs to test questionable patients in order to detect community infection at an early stage. The number of patients at the FSS directly from the airport was low (9, 0.3%). This is because the Taiwan CDC established fever screening and testing sites at the airports. Passengers landing in Taiwan with fever or respiratory symptoms must undergo COVID-19 testing and are subject to home quarantine for 14 days. As a result, very few required testing at the medical center. Testing is arranged for individuals who develop symptoms while in quarantine. To avoid patients with infection risk presenting to the ED as walk-in patients, the government set up a CDC hotline (1922) for medical assistance. The CDC would arrange transport and alert the hospital of patient arrival. However, our study showed that 80.3% of the patients screened at the FSS presented to the ED as walk-in and 1.5% were referred by CDC (1922) . This underscores the importance of FSS in screening and dividing the flow of walkin patients with stratified risks. Not only does FSS share the ED workload but also the OPD workload. About 10.2% (383/3755) of FSS patients were referred from the OPD. A majority, 55.6% (324/583), of high-risk patients had a travel history and 38.4% travelled to Asia. The Taiwanese government takes a step further to integrate immigration and customs database with the National Health Insurance (NHI) database; with a simple insertion NHI smart card, medical staff are immediately alerted on the screen of travel history, border entry, and home quarantine or isolation status. Medical staff with symptoms of viral infection are referred to the FSS for COVID-19 testing. Due to a travel ban for healthcare workers issued by the Taiwanese government on February 23, 2020, few medical staff had a travel history. Only 4.6% of the staff tested fell under high risk. Medical staff tested for COVID-19 require two negative test results 24 hours apart and 24-hour symptom-free status before return to work. Symptoms, along with TOCC, serve as important components of CDC case definition. 6 A study of 321 imported COVID-19 cases to Taiwan revealed only 44.9% had fever, three-quarters of had respiratory symptoms, 13.1% had loss of smell or taste, and 7.2% had diarrhea. 11 This signifies that body temperature screening at the ED door does not ensure detection of all cases and can miss those without obvious symptoms. A graded approach in testing allows testing of even low-risk patients, who may not have been eligible for testing. Among the highrisk patients tested in TVGH, 48.2% had respiratory symptoms and 40.7% had fever. Among intermediate-risk patients, 61.5% had fever and 28.3% respiratory symptoms. Among the undetermined-risk patients, 81.3% had fever and 15% had respiratory symptoms. This extra caution in testing low-risk patients stems from that fact that many COVID-19 patients have mild or asymptomatic disease and would have been difficult to identify if their travel and contact history had not been available. 12 A long transmissibility period and the fact that asymptomatic or paucisymptomatic patients can transmit this disease make disease control challenging. [13] [14] [15] During the outbreak, to minimize the risk of exposure to respiratory droplets facing EPs and medical staff, rapid influenza diagnostic testing was suspended. Only swabbing was restricted for patients tested for COVID-19 in an isolation area with proper PPE. This is because symptoms of influenza-like illness (ILI) or COVID-19 are often indistinguishable. Furthermore, in response to the outbreak, Taiwan's CDC announced an extension for government-funded free anti-influenza (oseltamivir) prescription drugs for patients with ILI. In TVGH, 86.4% patients swabbed for COVID-19 were also tested for atypical respiratory panel with 7.1% positive for atypical pathogens. The small number of patients testing positive for influenza A or B may be the result of the use of oseltamivir by patients with ILI during the outbreak. A majority (76.4%) of high-risk patients were diagnosed with a disease of the respiratory system. It is not surprising as patients with the combination of TOCC and pneumonia fit the CDC case definition. On the other hand, 54.8% of intermediate-risk and 45.8% of undetermined-risk patients were diagnosed with a disease of the respiratory system. These patients had pneumonia, did not have pertinent TOCC, and did not fit the CDC case definition before admission. On the other hand, 32.9% of intermediate-risk and 39.3% of undetermined-risk patients had a final diagnosis of FUO. Patients with FUO usually require extensive workup during admission, but before admission, febrile patients without obvious focus at the ED were tested for COVID-19 per request by subspecialty. This explains why FUO was observed in 39.3% of undetermined-risk patients. A majority of the patients tested for COVID-19 were young (mean 43.9), robust, and mobile. Hence, 55.6% of high-risk and 86.2% of intermediate-risk patients, after swabbing, were discharged to their homes for quarantine. High-risk patients often show a combination of pneumonia and TOCC, which justifies the 43.9% admission rate. Patients at undetermined risk required admission but were tested by the request of subspecialty, with 61.7% admission rate. The measures implemented in TVGH during the COVID-19 outbreak may not be universally applicable to every hospital. Nevertheless, these measures can be referenced and modified accordingly to each hospital's unique condition. In conclusion, given the narrow window of opportunity to prepare for a surge in the COVID-19 pandemic, there is an immediate need to respond and modify the ED setup accordingly. The significance of maintaining a functional ED and healthcare system during a pandemic cannot be overemphasized. EDs are the frontlines for delivering lifesaving treatment when confronted with a serious and unpredictable emerging infectious disease. World Health Organization. Coronavirus disease 2019 (COVID-19) situation report 41 American College of Emergency Physicians; Emergency Nurses Association; Society for Academic Emergency Medicine. Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China Asymptomatic coronavirus infection: MERS-CoV and SARS-CoV-2(COVID-19) Available at https:// www.cdc.gov.tw/Category/MPage/V6Xe4EItDW3NdGTgC5PtKA Hospital visiting policies in the time of coronavirus disease 2019: a nationwide website survey in Taiwan Declining emergency department visits and costs during the severe acute respiratory syndrome (SARS) outbreak Impact of severe acute respiratory syndrome (SARS) outbreaks on the use of emergency department medical resources Protecting health care workers during the COVID-19 coronavirus outbreak-lessons from Taiwan's SARS response Analysis of imported cases of COVID-19 in Taiwan: a nationwide study Coronavirus disease (COVID-19) in a paucisymptomatic patient: epidemiological and clinical challenge in settings with limited community transmission Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing Transmission of 2019-nCoV infection from an asymptomatic contact in Germany A novel coronavirus emerging in China -key questions for impact assessment This study was supported by research grant from 109VACS-002 from Taipei Veterans General Hospital, Taiwan, Republic of China.