“Welcome to

All
Heroes”
Fakultas Kedokteran
Universitas Islam
Indonesia
The Holy Prophet said, “If you hear of an outbreak of
plague in a land, do not enter it; but if the plague
breaks out in a place while you are in it, do not leave
that place”
(Bukhari, #5728).

1400 Years ago...

 Screening ,Triage,
& Assesment of
Covid-19 Mirza Koeshardiandi,

Make it simple
Webinar of CORONA 2020 , Medical Faculty – Indonesian Islamic University
dr. Sp.An FIPM FIPP

• When a person first
Access a heatlhcare
system*
Covid-19 Care Pathway
Discontinue
• In the Emergency Unit/similar area Transmission-
Appropriate Infection-Prevention Controll Measures (IPC), based Precautions,
including Isolation, Personal Proetective Equipment (PPE) including isolation

Acuity-based Clinical Covid-19 Release from

Suspect
triage Assessment + Treatmen pathway
t
• Ask patient a series of • Assessment for severity of
• To sort Patients into Treat & isolate in :
simple question based disease For Asymptomatic Pts.
category based on Need • Health facility(1st-2nd)
on standardized case • Assessment of risk factors • 10 days after test
for Time-Sensitive • Community facility/
definition. • Arrange for Testing • Home ~WHO guideline possitive
Treatment
ASAP!!!
• Keep a distance at least
1 meter between. Mild OR Low Risk Moderate For Symptomatic Pts.
Including Asymptomatic Patients Condition Condition • 10 days after
Worsenin symptom onset
Improv g
Covid-19 case

*) Ad-hoc Community Screening Sites/ e

• Plus at least 3 days
Not Suspected

Community Health Wokers/ Clinics/ Health Posts/

Hospitals/ Ambulances/ Phone-Telemedicine/
High Risk Moderate OR Treat & isolate in : without symptom :
Pharmacies/ Long term Healthcare Facilities Severe OR Critical • Health facility (tertiary) • Respiratory
• Fever

Non Covid-19 Care Negative Test

pe r ol ca l WHO guidelines,CDC, kemenkesRI 2020

 Screen for Covid-19 “Standardized Case definition”
early recognition of patients with COVID-
19
Definisi operasional kasus COVID-19 yaitu :

1. Kasus Suspek : ,
a. ODP
b. PDP

2. Kasus Probable,
3. Kasus Konfirmasi,

4. Kontak Erat,
5. Pelaku Perjalanan,

6. Discarded,
7. Selesai Isolasi, dan
8. Kematian. 41
 Screen for Covid-19
early recognition of patients with COVID-
19
*ISPA yaitu demam (≥38oC) atau riwayat demam;
dan disertai salah satu gejala/tanda penyakit
1. Kasus Suspek pernapasan : batuk/sesak nafas/sakit
tenggorokan/pilek/pneumonia ringan hingga
Seseorang yang memiliki salah satu dari kriteria berikut berat

:
a. ISPA* DAN pada 14 hari terakhir sebelum timbul ** Negara/wilayah transmisi lokal adalah
gejala negara/wilayah yang melaporkan adanya kasus
konfirmasi yang sumber penularannya berasal
memiliki riwayat : dari wilayah yang melaporkan kasus tersebut.

• perjalanan atau tinggal di negara/wilayah Negara transmisi local : https://www

Indonesia
yang melaporkan transmisi lokal**.
• kontak dengan kasus konfirmasi/probable COVID-
.who.int/emergencies/diseases/n ovel-
coronavirus-2019/situation-reports
Wilayah transmisi lokal di Indonesia:
https://infeksiemerging.kemkes.go.id.

19.
b. ISPA berat/pneumonia berat*** yang membutuhkan
perawatan di rumah sakit DAN tidak ada penyebab
lain berdasarkan gambaran klinis yang meyakinkan.
 Screen for Covid-19
early recognition of patients with COVID-
19
2. Kasus Probable
Kasus suspek dengan ISPA Berat/ARDS***/meninggal
dengan gambaran klinis yang meyakinkan COVID-19
DAN belum ada hasil pemeriksaan laboratorium RT-PCR.
We recommend, for all suspect
cases,
1. Collection of upper respiratory tract (URT)
specimens (nasopharyngeal and oropharyngeal)
where clinical suspicion remains and URT
specimens are negative, to collect specimens
from the lower respiratory tract (LRT) when
readily available (expectorated sputum, or
endotracheal aspirate/bronchoalveolar lavage in
ventilated patient).

3. Kasus Konfirmasi 2. Testing by reverse transcription polymerase

chain reaction (RT-PCR) and, In addition, testing
for other respiratory viruses and bacteria should
Seseorang yang dinyatakan positif terinfeksi virus be considered when clinically indicated.
COVID- 19 yang dibuktikan dengan pemeriksaan
laboratorium RT- PCR. SARS-CoV-2 antibody tests are not
recommended for diagnosis of current
Kasus konfirmasi dibagi menjadi 2: infection with COVID-19
a.Kasus konfirmasi dengan gejala (simptomatik)= (OTG)
b.Kasus konfirmasi tanpa gejala (asimptomatik)
 Screen for Covid-19 Pada kasus probable atau konfirmasi yang bergejala
(simptomatik),
early recognition of patients with COVID- untuk menemukan kontak erat periode kontak dihitung
19 dari 2 hari sebelum kasus timbul gejala dan hingga 14
hari setelah kasus timbul gejala.

4. Kontak Erat Muncul gejala/simptomatik Saat Datang

di Faskes RT PCR

Orang yang memiliki riwayat kontak dengan kasus

probable
Timeline pasien probable / konfirmasi +
2 hari 14 hari/sampai saat ini
atau konfirmasi COVID-19.
Riwayat kontak yang dimaksud antara lain:
a. Kontak tatap muka/berdekatan dengan kasus probable atau kasus
Pada kasus konfirmasi yang tidak bergejala
konfirmasi dalam radius 1 meter dan dalam jangka waktu 15 menit
(asimptomatik),
atau lebih.
untuk menemukan kontak erat periode kontak dihitung
dari 2 hari sebelum dan 14 hari setelah tanggal
b. Sentuhan fisik langsung dengan kasus probable atau konfirmasi
pengambilan spesimen kasus konfirmasi
(seperti
bersalaman, berpegangan tangan, dan lain-lain).
Saat Datang di Faskes
c. Orang yang memberikan perawatan langsung terhadap kasus RT PCR
probable
atau konfirmasi tanpa menggunakan APD yang sesuai standar.
d. Situasi lainnya yang mengindikasikan adanya kontak berdasarkan Timeline pasien asimptomatik konfirmasi +
penilaian risiko lokal yang ditetapkan oleh tim penyelidikan
epidemiologi setempat (penjelasan sebagaimana terlampir). 2 hari 14 hari/sampai saat ini
 Screen for Covid-19
early recognition of patients with COVID-
19

5. Pelaku
Perjalanan
Seseorang yang melakukan perjalanan dari dalam negeri (domestik) maupun luar negeri pada 14 hari
terakhir.

6. Kasus Discarded
Discarded apabila memenuhi salah satu kriteria berikut:
a.Seseorang dengan status kasus suspek dengan hasil pemeriksaan RT-PCR 2 kali negatif selama 2
hari berturut-turut dengan selang waktu >24 jam.
b.Seseorang dengan status kontak erat yang telah menyelesaikan masa karantina selama 14 hari.
 Screen for Covid-19 Saat Datang di Faskes
RT PCR
early recognition of patients with COVID- Isolasi 10 hari

19
7. Selesai isolasi Timeline pasien asimptomatik konfirmasi +
Selesai isolasi apabila memenuhi 2 hari 14 hari/sampai saat ini

kriteria berikut :
a. Kasus konfirmasi tanpa gejala
(asimptomatik) tanpa follow up RT-PCR → Isolasi 10 hari
10 hari isolasi mandiri sejak pengambilan
spesimen diagnosis konfirmasi. Muncul gejala/simptomatik
Follow up
Saat Datang

di Faskes

b. Kasus probable/kasus konfirmasi dengan RT PCR

gejala (simptomatik) tanpa follow up RT-PCR RT PCR

3 hari bebas gejala
→ 10 hari sejak tanggal onset dengan
ditambah
minimal 3 hari tanpa gejala demam Timeline pasien probable / konfirmasi + -
dan gangguan pernapasan.
Muncul gejala/simptomatik Saat Datang 2 hari Follow up
di Faskes RT PCR
14 hari/sampai saat ini
c. Kasus probable/kasus konfirmasi dengan RT PCR
3 hari
gejala (simptomatik) dengan follow up RT- bebas gejala
PCR 1 kali negatif, dengan ditambah minimal
3 hari setelah tanpa gejala demam dan
gangguan pernapasan. Timeline pasien probable / konfirmasi + -
 Screen for Covid-19
early recognition of patients with COVID-19

8. Kematian
Kematian COVID-19 untuk
kepentingan surveilans adalah kasus
konfirmasi/probable COVID-19 yang
meninggal.

Jadi bilamana ada kasus suspek di UGD sedang mendapat

pertolongan belum sempat MRS , kemudian meninggal
misalnya karena sesak nafas , Apakah termasuk Kematian
Covid-19 ?
SUSPECT
Suspek
Clinical criteria Case classification :
Any person with at least one of the following symptoms
• fever (83-99%)
• cough (59-82%) 1 Possible case: ~Suspect case
• shortness of breath (31-40%) Any person meeting the clinical criteria
• myalgia (11-35%)
• sudden onset of anosmia, ageusia or dysgeusia

Epidemiological criteria
At least one of the following two epidemiological links: 2 Probable case:
• close contact with a confirmed COVID-19 case in the 14 days prior to Any person meeting the clinical criteria with and
onset of symptoms epidemiological link
• having been a resident or a staff member, in the 14 days prior to onset
of symptoms, in a residential institution for vulnerable people where OR
ongoing COVID-19 transmission has been confirmed Any person meeting the diagnostic criteria

Diagnostic imaging criteria

Radiological evidence showing lesions compatible with COVID-19

Laboratory criteria 3 Confirmed case:

Detection of SARS-CoV-2 nucleic acid in a clinical specimen Any person meeting the laboratory criteria
1 Possible case: ~Suspect case
Any person meeting the clinical criteria

2 Probable case:
Any person meeting the
clinical criteria with and
epidemiological link
OR
Any person meeting
the
diagnostic criteria

3 Confirmed case:
Any person meeting the
laboratory criteria
Tidak diperlukan scoring system lagi
Tidak diperlukan pemeriksaan
Laboratorium lain kecuali dalam
Menilai derajat penyakit / severity
Of disease yang penting
Saat triage
 Acuity-based triage
Triage

Definisi Triage :
Triage definition :

• Pemilahan dan klasifikasi pasien atau korban untuk

menentukan prioritas kebutuhan perawatan dan
tempat yang sesuai. 1
• The sorting out and classification of patients owr ocrasseunani ltgies to determine priority of need and
of treatment 1
proper place
Mild OR Low Risk Moderate High Risk Moderate OR
.
Including Asymptomatic Patients Severe OR Critical
improving
1400 Years ago...

He also said, “Do not graze a sick herd with a healthy one, [or, Do not
put a sick patient with a healthy person]”

(Bukhari, #5771; Muslim, #2221).

AND just Now we Learn more about : Screening , Triage ,

Isolation
Acuity-based triage
Triage
Acuity-based triage
Triage
Acuity-based triage
Triage
Acuity-based triage
Triage
Acuity-based triage
Triage
 Pain Treatment
Principles
during Pandemic
Covid-19 Mirza Koeshardiandi,
dr. Sp.An FIPM FIPP

Webinar of CORONA 2020 , Medical Faculty – Indonesian Islamic University

Pain Treatment Principles During Covid-19 Pandemic

In‐patient visits
• Any elective in‐person patient visits or meetings should be suspended.
• No elective pain procedures should be performed, except specific semi‐urgent procedures.

Use of telemedicine
• Use telemedicine as the first approach and exclusively in most cases.
• Ensure adherence to the subscribed needs of telemedicine required by individual state or country of
practice.

Biopsychosocial management of pain

• Telemedicine platforms are available to engage in multidisciplinary interactions.
• Whenever possible, online self‐management programmes that integrate components of exercise, sleep
hygiene, pacing and healthy lifestyle should be considered.
• Multidisciplinary therapies could be helpful in overcoming increased opioids needs and/or procedures
during the pandemic.
Pain Treatment Principles During Covid-19 Pandemic

Prescribing opioids
• Use telemedicine to evaluate, initiate and continue opioid prescriptions.
• Ensure all patients receive their appropriate prescription of opioids to avoid withdrawal.
• Naloxone education and prescription for high‐risk patients.
• Inform patients of the risks and impact of long‐term opioid therapy on the immune system.
• Communicate with other healthcare providers in the patients’ circle‐of‐care including family physicians,
pharmacists and nurses.

Principles for using NSAIDS

• We recommend all patients prescribed or who use non‐steroidal anti‐inflammatory drugs on a regular basis
to continue their use, whilst monitoring for adverse effects.
• We recommend educating patients on non‐steroidal anti‐inflammatory drugs that any mild fever or new
myalgia should be promptly reported.
 Anti‐inflammatory
drugs
• NSAIDs exert analgesic effect primarily → peripheral inhibition of prostaglandin
synthesis
• Inhibit Cyclo‐oxygenase enzyme, (COX‐1 and COX‐2).
• Antihypertensive actions of angiotensin converting enzyme (ACE) inhibitors involves the
kinin‐prostaglandin system → increase the levels of ACE.
• French health minister advice against the use of ibuprofen or other NSAIDs, → may
increase the severity of COVID‐19 disease .
• However this has not been substantiated by other any reports and multiple regulatory
bodies have since refuted this assertion .

• However, NSAIDs may mask early symptoms of the disease such

as
fever and myalgias.
Pain Treatment Principles During Covid-19 Pandemic

Principles for using Steroids

• Steroids increase potential for adrenal insufficiency and altered immune response.
• Intraarticular steroid injections could increase the risk of viral infection.
• Duration of immune suppression could be less with the use of dexamethasone and betamethasone.
• Consider evaluating risks and benefits of steroid injections and use a decreased dose

Intrathecal drug delivery systems

• Avoid insertion of any new intrathecal pump (ITP) except for highly selected cancer pain cases where the
benefit is considered to outweigh the risk. Consider proceeding straight to an implant, without a trial, for
appropriate candidates.
• In COVID‐19 suspected or symptomatic patients, consider the possibility of delaying the refill if the low reservoir alarm date allows a
time
frame until the patient has served a recommended self‐isolation period.
• Following a thorough discussion with the patient, consider: the risk benefit balance of discontinuing ITP therapy in high‐risk patients on
ziconotide therapy where no withdrawal effects have been reported; and the risk benefit ratio of using higher drug concentrations for the
period of the pandemic in order to reduce ITP refill related visits.
Pain Treatment Principles During Covid-19 Pandemic

Neurostimulator issues
• Avoid any new trials or implants.
• Use telemedicine as much as possible to resolve patient concerns. An audiovisual interview makes it
easier to evaluate or troubleshoot most issues.

Principles for semi‐urgent visits/procedures

• Comprehensive evaluation required and the need to help patients make informed decisions.
• Use telemedicine to evaluate the patient, triage the urgency, and make suitable arrangements for
treatment. This will minimise delay and prevent unnecessary visits.
“Whoever believes in Allah and the Last Day
should not harm his neighbour [or physically
next to himself].”

(Bukhari, #6018).