Containing COVID‐19 in the emergency room: the role of improved case detection and segregation of suspect cases

Abstract

[Abstract]. Aims: Patients with COVID‐19 may present with respiratory syndromes indistinguishable from common viruses. This poses a challenge for early detection during triage at the emergency department (ED). Over a 3‐month period, our ED aimed to minimise nosocomial transmission by using broader suspect case criteria for better detection and using appropriate personal protective equipment (PPE) for healthcare workers (HCWs). Methods: All ED admissions with respiratory syndromes over a 3‐month period were tested for COVID‐19. The sensitivity and specificity of screening criteria in detecting COVID‐19 was assessed. A risk‐stratified approach was adopted for PPE usage in the ED, based on high‐risk “fever areas” and lower‐risk zones. When a case of COVID‐19 was confirmed, surveillance was conducted for potentially exposed patients and HCWs. Results: A total of 1,841 cases presenting with respiratory syndromes required admission over the study period. Amongst these, 70 cases of COVID‐19 were subsequently confirmed. The majority (84.2%, 59/70) were picked up at ED triage as they fulfilled suspect case criteria. Of these, 34 met the official screening criteria; another 25 were picked up by the broader internal screening criteria. Over the 12‐week period, the cumulative sensitivity of internal screening criteria was 84.3% (95% confidence interval, CI=73.6%‐91.9%), whereas the sensitivity of the official screening criteria was 48.6% (95%CI=36.4%‐ 60.8%). Given the broadened internal criteria, the pre‐existing ED “fever area” was insufficient and had to be expanded. However, there were no cases of nosocomial transmission from intra‐ED exposure, despite extensive surveillance. Conclusion: Frontline physicians need to be given leeway to decide on the disposition of cases based on clinical suspicion during an ongoing outbreak of COVID‐19. If a broader criterion is used at ED triage, ED facilities and isolation facilities need to be readied to accommodate a surge of suspect cases. Usage of appropriate PPE is essential in minimising nosocomial transmission.