Triage is a central task in an emergency department . Triage aim to provide the hospital an opportunity for early isolation of cases that may cause public health outbreak for infectious diseases. Different hospitals use different protocols to divert suspected cases in the proper area of the the emergency department. Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) is a novel coronavirus discovered in 2012 and is responsible for acute respiratory syndrome in humans. Mortality among patients with MERS-COV infection has been reported to be 36% .Transmission of infectious diseases through medical staff and patients has become a serious issue in the emergency department . The Middle East respiratory syndrome-coronavirus (MERS-CoV) epidemic has a significant impact in the EDs in Saudi Arabia. MERS-CoV first discovered in Saudi Arabia in September 2012. Later they determined that the first case of MERS was in Jordan in April 2012.
Due to the overcrowding of the emergency department, the patient was held in the hospital for necessary additional diagnostic and curative intervention. While this time he was treated in an open area with no isolation from other patients and visitors and this permitted nosocomial spread of MERS-COV and other infectious diseases to adjacent patients, medical staff and visitors.To prevent the outbreak of acute respiratory illness in the emergency department, KFMC engaged guidance for patients who should be tested for MERS-COV OR influenza H1N1.Triage helps to divert the patients who need isolation to proper area to prevent transmission of the MERS-COV. Visual triage score in King Fahad Medical City is essential to improve early admission of patients who come to the emergency department with flu-like symptoms (fever, cough, shortness of breath).Triage scales tend to provide the chance for the hospital to reassess its screening and isolation program related to a public health emergency for an infectious disease.
In Saudi Arabia, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) has highly increased in the mid-March 2014; this sharply increased raised international worry of global outbreak . To limit transmission of respiratory viruses including MERS-CoV in emergency department requires the utilization of infection control protocols and procedures . The emergency department made a protocol for patients who need isolation to pick up all cases that have symptoms of MERS-COV. Majority of recorded cases have been from Saudi Arabia.Camels are considered the source of MERS-COV infection . Human to human transmission of MERS-CoV occurs through droplet, direct contact with the infected patient or by touching contaminated surfaces .
The protocol increased the ability of the emergency department to control and prevent the possible spread of MERS in health care facilities . MERS may at first show no symptoms it is like other respiratory infections, the initial symptoms of MERS are non-specific . Therefore, medical staff should always implement standard precautions with all patients.
Some people with MERS-COV have no symptoms, and some of them have mild symptoms such as flu-like symptoms. Individuals with MERS-COV infection have symptoms of respiratory tract illness with fever, cough, and shortness of breath. Extrapulmonary symptoms include diarrhea, nausea, and vomiting. In some cases the have ecomplications like kidney failure and pneumonia. People with weakened immune system or having medical conditions such as diabetes, chronic lung cancer, heart disease or cancer have more chance to be infected with MERS-COV
Triage Systems and the MERS-COV Patient
The hospital ED is one of the most important constituents of the healthcare delivery system. As is in most countries, improving the use of EDs in Saudi Arabia is still the subject of research. The emergency department triage is often the first process in the medical care for patients who need acute care. According to Fitzgerald and colleagues (2010), the purpose of the triage is to apply evidence from the objective observation of the patients characteristics in order to prioritize need for emergency treatment. The triage process involves the nursing and medica staff sorting and selecting as well as categorizing patients who are presented for emergency care in order to sustain the patients life.
ED triage has its antecedents in the practice of military, civilian and disaster medicine (Mezza, 1992). The conventional prioritization of patients needs for emergency care was the duty of the emergency physician although the role has been taken over in the past few decades by the emergency department nurses (Bullard et al., 2008). Since the MERS-CoV disease was first discovered in Saudi Arabia, more than six hundred patients have died due to the disease. These cases could have been avoided if they were diagnosed early enough. Visual triage scores could be potentially play a vital role in the detection of the disease.
The symptoms of MERS CoV include fever, cough, shortness of breath, runny nose, sore throat, body ache, and nausea /vomiting, and diarrhea. According to Ontario Agency for Health Protection and Promotion (2016) patients had presented these signs of the disease in 26 countries where more than 600 people had died from the disease. Perhaps early detection of the disease could have averted some of these deaths. Development of protocols for diagnosis of illness in ED for emergency care based on its signs and symptoms may improve the quality of healthcare.
ED visual triage scores play a major role in early detection of the MERS-CoV. Previous studies have explored the use of triage in early detection of various types of disease with positive outcomes. The triage process involves two stages which the assessment stage in which the triage category is allocated as well as the patient processing and the intervention phase which facilitates emergency care for the patient. The expected outcomes of the triage include correct, expected, over- and under triage. When the patient is examined within the correct timeframe, the correct triage which represents a positive health outcome is obtained. Sometimes, a triage category can be allocated an over-triage or under-triage to a higher or lower acuity than required respectively. Previous studies indicate that over-triage and under-triage are can have costly outcomes to healthcare whereby the emergency department resource allocation can be higher than is necessary, longer patient waiting times, and associated complications [Wuerz, Fernandes and Alarcon, 1998; Gerdtz and Bucknall, 2000].
Gerdtz and Bucknall examined the effect of triage on waiting times. They found that over-triage and under-triage allocation is leads to prolonged waiting times and can result in more complications due to the long waiting times. However, the argument may not be so much about waiting times but rather about equitable redistribution of patient waiting times according to need in order to avoid the deleterious impacts of waiting long. Wuerz, Fernandes and Alarcon noted in their study that prolonged waiting times brought about by long triage was one of the main sources of emergency department dissatisfaction by patients and families. However, triage is an important process that needs to be embraced by both the healthcare professionals and patients in order to improve the satisfaction outcome. The WHO (2010) recommended educational campaigns to educate healthcare professionals, patients, and families about the importance of triage.
The study was a retrospective observational study that involved assessment of all adult ED patients who have visual score of 3 or more symptoms suggestive of MERS-COV (fever, cough, shortness of breath, runny nose, sore throat, body aches nausea, vomiting or diarrhea and patient previously exposed to MERS-COV within 2 weeks and coming from an outbreak area). The study included all patients who walked to the King Fahad Medical City and were asked to answer the visual triage scoring checklist for acute respiratory illness. The sample size of the participants was 397 patients. Then, patients were isolated in a negative pressure room where all nurses and medical staff take full precaution. In the first two hours, all patients were screened for CBC and chest x-ray, then the physician decided if the patient needed to be swabbed or not. If the first swab was negative, they needed a second swab and if the first swab was positive they kept the patient in the isolation room.
Patients suspected of MERS-CoV who were 14 years and older were included in the study and surveillance guidance. In addition, the following patients were included in the assessment.
A person with fever and community-acquired pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence. OR
A hospitalized patient with healthcare associated pneumonia based on clinical and Radiological evidence. OR
A person with 1) acute febrile (380C) illness, AND 2) body aches, headache, diarrhea, nausea/vomiting, with or without respiratory symptoms, AND 3) unexplained leucopenia (WBC<3.5x109/L) and thrombocytopenia (platelets<150x109/L)3. OR
A person (including health care workers) who had protected or unprotected exposure to a confirmed or probable case of MERS-CoV infection and who presents with upper5 or Lower respiratory illness within 2 weeks after exposure.
All patients with suspected cases of MERS-COV had a nasopharyngeal swab obtained from the posterior nasopharynx. If the patients were confirmed (MERS-COV) they were transferred the patient to Prince Mohammed Bin Abdulaziz Hospital but if not, they were sent for second swab after 48 hours then every three days,if still positive but clinically improving and stable ; they will discuss with the patient/family for home isolation.And they will inform the Ministry Of Health for follow up.
Data collection and Analysis
A Cross sectional chart review was performed of all ED patient files that proceeded to the respiratory zone area suspected of MERS-CoV infection during the study period. Data collected from the charts included MRN, age, out- come of nasal swab, visual triage score, date of swabs and visit date. Those patients who were swabbed were then compared with patient's chart and how many of them met with the case definition criteria. The swab was taken from patients file software (cortex) and the data collected was transferred into an excel sheet. The data was transferred to SPSS and analyzed using univariate, and bivariate analysis techniques.
The total valid number of patients in this study was 397. Of all the patients screened, 48.8% (n = 189) were female and 51.2% (198) were male patients. The average age of the patients was 54 years (SD = 21.624).
Figure 1. The percentage of patients detected of MERS-COV in the sample population after recording the visual triage scores and subsequent swabbing. Upon analysis, the results show that 2.3% of the patients tested positive of MERSOV.
Paired sample tests were performed to find any significant relationships between various predictors of the CTAS scale and their respective scores (See Table 1.). The findings show that all independent variables (fever, cough, shortness of breath, runny nose, sore throat, body ache, nausea, vomiting, and diarrhea as well as exposure to MERS-COV) are significantly associated with the visual triage score (p<0.05).
Table 1. The relationship between independent predictors and the CTAS...
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