ZONASI DAN TRIAGE IGD

DI ERA COVID-19
Wahyuni Dian Purwati
PERSI – 28 Oktober 2020
 OUTLINE

• Emergency Department
• Emergency Department • Triage flow for covid-19
services during Covid -
Screening for Covid-19 patients
19 Pandemi
 Covid-19 in Indonesia

2 March 2020 24 October 2020

Impact of Covid-19 Pandemic
on Emergency Department
 TOTAL ED PATIENTS ALL SHG
FEBRUARY – APRIL 2020
40000

35000 34207
30865
30000

25000

20000
17026
15000

10000

5000

0
Feb-20 Mar-20 Apr-20
 Triage 1 & 2 Patients by Type of Diseases
(MRCCC, SHLC, SHTB, SHKJ)
Total Triage 1 Patient by 3 type of disease (Road Total Triage 2 Patient by 3 type of disease (Road
Accident, Cardiac, Stroke) – Feb – Apr 2019 & 2020 Accident, Cardiac, Stroke) – Feb – Apr 2019 & 2020
350 350
TRIAGE 2
TRIAGE 1
34%
300 67% 300
decreased
decreased
from 2019
from 2019
250 250

203
200 200

150 150

100 88 100

53 53
50 32 50

11
5
0 0
MRCCC SHKJ SHLC SHTB MRCCC SHKJ SHLC SHTB

Feb-Apr 2019 Feb-Apr 2020 Feb-Apr 2019 Feb-Apr 2020

AMA Intern Med. 2020;180(10):1328-1333. doi:10.1001/jamainternmed.2020.3288.
 Challenges

• Provided high • Prevent spread infectious

quality emergency disease between patients
services and staffs
Walton H, et al. Emerg Med J 2020;0:1–5. doi:10.1136/emermed-2020-210220
Emergency care of high quality :
• Delivered in an environment where staff and patients are safe from harm
• Where the experiences of receiving and delivering care are positive
• Where emergency care improves the health of communities

Australasian College for Emergency Medicine

 Global Response to COVID-19 for Emergency
Healthcare Systems and Providers
• Immediate and aggressive measures to limit transmission of COVID-19.
• Ensure that frontline providers have adequate PPE or PPE alternatives if resources run
out.
• Develop institution-specific policies regarding staffing based on demographics of
emergency care providers.
• Immediate emergency department functional re-design
• Separate high risk and low risk Covid-19 Patient care areas and staff where possible.
• Preserving an area in the ED for only acutely ill suspect or known COVID 19 patients who need
resuscitation
• Deployment of resources (pre-hospital) such as mobile Covid-19 teams that can set up
clinics or provide care at nursing homes, shelters etc, and ambulances for the care of
COVID-19 cases

International Federation for Emergency Medicine

 General Principle
• EDs must develop clear processes to identify and isolate patients who
may be a source of disease transmission
• All patients should be considered as potentially infectious.
• Some patients present with atypical symptoms (especially children
and older persons), for this reason, clinicians should exercise a high
degree of suspicion and vigilance at all times.

Australasian College for Emergency Medicine

Australasian College for Emergency Medicine
 EMERGENCY DEPARTMENT ZONATION
• Reorganized emergency department into 3 zones (red,
yellow, and green) for the purpose of reducing cross-
infections and minimizing demand for PPE.
• Red zones : high or medium risk of COVID-19 infection patients
• Yellow zones : low risk of COVID-19 infection patients
• Green zones : healthcare providers (HCPs) for personal protective
equipment (PPE) donning, inventory, planning, and dining.

Chong, Dividing the Emergency Department into Red, Yellow, and Green Zones to Control COVID-19 Infection; a Letter to Editor
Academic Emergency Medicine. 2020; 8(1): e60
Basic Layout Principle for Covid-19 Facility

World Health Organization (WHO). Home care for patients with suspected novel coronavirus ( nCoV )
infection presenting with mild symptoms and management of contacts. 4–6 (2020).
Basic Layout Principle for Covid-19 Facility

SEVERE ACUTE RESPIRATORY INFECTION (SARI) TREATMENT FACILITY DESIGN

EMERGENCY DEPARTMENT ZONATION

Chong, Dividing the Emergency Department into Red, Yellow, and Green Zones to Control COVID-19 Infection; a Letter to Editor
Academic Emergency Medicine. 2020; 8(1): e60
EMERGENCY DEPARTMENT ZONATION
Patients with suspected or confirmed COVID-19
who are undergoing, or are likely to undergo, an
aerosol generating procedure

• Patients with suspected or confirmed

COVID-19 receiving supplemental
oxygen.
• Other patients with confirmed COVID-
19.

Other patients with suspected COVID-19

 The Hierarchy of Isolated Treatment Spaces

While patients with suspected or confirmed COVID-19 should ideally be managed

in a negative pressure room, this may not be feasible as patient numbers escalate.

Australasian College for Emergency Medicine

 Patient Cohorting
• In the event of overwhelming patient demand, it may be necessary to cohort
patients with suspected and/or confirmed COVID-19 in an open or shared area of
the ED
• If cohorting is required, EDs implement the following strategies to optimise
patient and staff safety:
• Ensure the area is clearly demarcated.
• Decrease passage by minimising entry and exit points and limiting the presence of non-
essential personnel.
• Physically separate patients to the extent that is possible, aiming for a distance of at least
1.5m between individuals.
• Ensure all patients, where it is clinically safe to do so, are wearing a surgical mask.
• Educate staff regarding standards and strategies for optimal PPE and infection prevention and
control.
• Arrange for this area to be cleaned regularly
• Adjust air-conditioning and ventilation flows to decrease the risk of aerosol transmission.

Australasian College for Emergency Medicine

 Patient Cohorting
• Patients with suspected COVID-
19 should ideally be cohorted
separately from those with
confirmed infection.
• When all patients in a shared
treatment space have confirmed
infection, they may be cohorted
together without the same
physical distancing
requirements.
T. Whiteside et al. / American Journal of Emergency Medicine 38 (2020) 1448–1453
Redesigning emergency department operations amidst a viral pandemic
 Triage
• Triage is key to early recognition and rapid initiation of infection
control precautions, the most important strategies for controlling viral
respiratory disease outbreaks
• During a pandemic, principles of triage include a triage system that:
• Simple and easy to use and facilitates rapid processing of patients presenting
to the ED.
• Will identify and isolate those at increased risk of disease, reducing potential
for transmission to other patients and health staff.
• Can be easily taught and reliably applied by credentialed staff.

Australasian College for Emergency Medicine

 Standard Operating Procedure (SOP) for Triage of Suspected
COVID-19 Patients in non-US Healthcare Settings

• Communicate with patients before they arrive

for triage
• Set up and equip triage (e.g., availability of
medical masks for people with COVID-19
symptoms)
• Set up a separate COVID-19 waiting area
• Establish triage process
• Train staff on infection prevention and control
measures including proper use of personal Intended for use in non-US healthcare
protective equipment settings. Document can be found at:
https://www.cdc.gov/coronavirus/2019-
ncov/hcp/non-us-settings/sop-triage-prevent-
transmission.html
Communicate with patients
Before arrive for triage
 Set up and equip triage
Set up a separate COVID-19 waiting are
A separate, well-ventilated area Medical mask and paper tissues at Regular
where patients with suspected registration desk Waiting
COVID-19 can wait Area

This area should have:

• Benches, stalls or chairs separated
by at least one-meter distance ​
• Dedicated toilets and hand
hygiene stations​ Physical barriers (glass
or plastic screens)
• Paper tissue, alcohol-based hand
sanitizer, and trash bin with lid​
• Clear signs informing the location
of a separate COVID-19 waiting Hand hygiene
area A bin with lid for discarding
stations

• Limit the number of accompanying used paper tissues

family members in the waiting area
Standard Operating Procedure (SOP) for Triage of Suspected COVID-19
Patients in non-US Healthcare Settings
 TRIAGE

Standard Operating Procedure (SOP) for Triage

of Suspected COVID-19 Patients in non-US
Healthcare Settings
 TRIAGE

Coronavirus‐19 Pandemic: A Two‐step Triage Protocol for Emergency Department

Journal of Emergencies, Trauma, and Shock; Volume 13 ; April-June 2020
 Flowchart for Triaging Patients presenting to The ED

Chen-June Seak, Rapid responses in the emergency department of Linkou Chang Gung Memorial Hospital, Taiwaneff ectively
prevent spread of COVID-19 among healthcare workers of emergency department during outbreak: Lessons learnt from SARS , Biomedical Journal 4 (2020)
 TOCC screening questionnaire

Chen-June Seak, Rapid responses in the emergency department of Linkou Chang Gung Memorial Hospital, Taiwaneff ectively
prevent spread of COVID-19 among healthcare workers of emergency department during outbreak: Lessons learnt from SARS , Biomedical Journal 4 (2020)
 Strategies to avoid overcrowding at triage
and preserve PPE
• Cancel non-urgent outpatient visits to ensure enough HCWs are
available to provide support for COVID-19 clinical care, including
triage services
• If outpatient visit is critical (such as immunization of infants or pre-natal care for high-risk pregnancy),
identify separate/dedicated entrance for these patients
• Reinforce telemedicine or other alternative to face-to-face visit

• Postpone or cancel elective procedures and surgeries to minimize

exposure and to preserve PPE for HCWs caring for COVID-19 patients
• Expand hours of operation, if possible, to limit crowding in triage
during peak hours
Screening for Health Facility

SEVERE ACUTE RESPIRATORY INFECTION (SARI) TREATMENT FACILITY DESIGN

 COVID-19 EWS
CONCLUSIONS
The new developed
COVID-19 EWS was a
considerable tool for
early and relatively
accurately warning of
SARS-CoV-2 infected
patients.

Cong-Ying Song , COVID-19 early warning score: a multi-parameter screening tool to identify highly suspected patients
 • NEWS2 score at emergency
department admission predicted
severe disease and in-hospital
mortality and was superior to qSOFA
and other clinical risk scores for this
purpose.
• A NEWS2 score ≥ 6 predicted severe
disease with 80.0% sensitivity and
84.3% specificity.
• Conclusion: NEWS2 score at hospital
admission predicted severe disease
and in-hospital mortality, and was
superior to other widely used clinical
risk scores in patients with covid-19.
Myrstad et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2020) 28:66
https://doi.org/10.1186/s13049-020-00764-3
 An Early Warning Score to predict ICU
admission in COVID-19 Positive Patients

• These data suggest that EWS

may help clinicians identify in
advance COVID-19 patients who
will require ICU admission

Letter to the Editor https://doi.org/10.1016/j.jinf.2020.05.047 2020

The British Infection Association. Published by Elsevier Ltd. All rights reserved.
Triage Clean zone

Covid Zone
Covid Zone
Developing Protocols with Subject Matter Experts

Pulmonologist
Anesthesiologist
Internist
ENT
Clinical Pathologist
Radiologist
Pediatrician
Obstetrician
Onsite telemedicine strategy for coronavirus
(COVID-19) screening to limit exposure in ED

Chou E, et al. Onsite telemedicine strategy for coronavirus (COVID-19) screening to limit exposure in ED,
Emerg Med J June 2020 Vol 37 No 6
Transfer of Knowledge from The Expert
Coordination Meeting and Daily Morning Meeting
Online Counseling (For Staff and Patients)
Learning From Global Experience

• Conference Call With Zhong Shan

Hospital (Shanghai & Wuhan)
• Conference Call with National
University Hospital, Singapore
The Public Shows their Appreciation for Our Teams
 TAKE HOME MESSAGES
• Reorganized emergency department into 3 zones to reduce
cross-infections and minimizing demand for PPE
• Simple and easy to use triage system that will identify and
isolate infection, easily taught and reliable to applied
• Early screening in ED using scoring system
• Telemedicine strategy to limit exposure
TERIMAKASIH
COVID-19 EWS

Coronavirus Disease 2019: Tinjauan Literatur Terkini

Onsite telemedicine strategy for coronavirus
(COVID-19) screening to limit exposure in ED

Chou E, et al. Onsite telemedicine strategy for coronavirus (COVID-19) screening to limit exposure
in ED, Emerg Med J June 2020 Vol 37 No 6