Pandemic Emergency Department Triage Screening: Symptoms Increase Sensitivity
Joseph B. Miller
Henry Ford Health System
INTRODUCTION: In the weeks following the January 20, 2020, announcement of the first confirmed case of COVID-19 in the United States, valuable data was published on the clinical characteristics, inclu..more »
INTRODUCTION: In the weeks following the January 20, 2020, announcement of the first confirmed case of COVID-19 in the United States, valuable data was published on the clinical characteristics, including the most common presenting symptoms of individuals affected with the disease. One study in Wuhan, China, identified fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%) as common symptoms. A second study in Washington State identified shortness of breath as an initial symptom in 76% of patients. This case highlights the importance of rapid incorporation of updated data on the symptomatology of diseases into triage screening questionnaires during pandemics.
CASE REPORT: Days after the World Health Organization’s March 11, 2020 declaration of a pandemic, a 37-year-old female presented to our Emergency Department (ED) with a 4-day history of cough, shortness of breath, myalgias, and fever. In triage, the patient was asked if she had traveled outside of the United States and if she had close contact with any person that had laboratory-confirmed COVID-19, for which she answered no. While waiting to be evaluated, the patient spent approximately 40 minutes in triage and an ED hallway before the possibility of COVID-19 was considered. At that point, airborne isolation precautions were ordered. Upon further questioning, the patient revealed she had taken a public bus trip to Florida, 6 days prior. She stated that several passengers on the bus were complaining of flu-like symptoms and were coughing. Upon arrival in Florida, the patient began developing a cough. As her symptoms progressed she also developed headache, nausea, and diarrhea, prompting her to return to Detroit to seek medical attention. The patient had multiple chronic health conditions, including hypertension, insulin-dependent type 2 diabetes, and obesity with a BMI of 48. The patient was subsequently admitted and was later confirmed to be positive for COVID-19.
DISCUSSION: Historically, beta-coronaviruses have high rates of transmissibility in healthcare settings. A review of a 2014 MERS outbreak in Saudi Arabia classified 43.5% of all cases as nosocomial infections, while other outbreaks in Saudi Arabia in 2013 and South Korea in 2015 linked 100% to healthcare settings. Studies of the 2002-2003 SARS outbreak found that 21% of all cases occurred in healthcare workers and that the admission of a single index patient in one hospital led to a disastrous superspreading that infected 76 individuals. Data for COVID-19 is still limited, but one series in Wuhan, China presumed that 29% of hospitalized patients with COVID-19 pneumonia acquired the disease in a healthcare setting. It is important to maximize the utility of any tool that has the potential to reduce exposure of a contagious disease to healthcare workers and hospital patrons. Containment and isolation practices are significantly less effective during pandemics that have asymptomatic carriers and lengthy pre-symptomatic states, hence we should not lose opportunities to immediately isolate individuals who are showing symptoms. Another important consideration is that all SARS superspreaders were symptomatic. This case highlights the importance of rapid incorporation of updated data on the symptomatology of a disease into triage screening questionnaires in the setting of an evolving pandemic. This patient presented to our emergency department with a constellation of symptoms that were associated with COVID-19. She had close contact with individuals with the same symptoms while traveling. However, the triage screening questions utilized were not sensitive enough. Shortly after this incident, our institution modified the questionnaire to include specific symptoms associated with the disease, including fever, cough, shortness of breath, and myalgias, which would have potentially identified this patient earlier and expedited the placement of isolation orders.
Wayne State University
WSU Medical School
Henry Ford Health System
Henry Ford Hospital