The COVID-19 pandemic has completely engaged the entire community of health workers. The disease is being analyzed from the perspective of epidemiology, etiology, pathogenesis, clinical manifestations of the disease, best diagnostic criteria, and treatment protocols. At the same time, the need for a complete reorganization of the healthcare system has arisen.
The Emergency Center of the University Clinical Center of Serbia (EC-UCCS) has been a non-covid hospital since the beginning of the pandemic. However, 20-25% of patients suffering from the COVID-19 infection require some form of intensive care ,, which is why it is to be expected that some of them, as patients with an emergency condition, will come to non-covid healthcare facilities, especially to the EC. Furthermore, as this is a hospital with considerable resources, and certain emergency conditions (in the domain of cardiac surgery, vascular surgery, microsurgery) on the territory of the City of Belgrade and in the surrounding area can be treated 24/7 only at the UC, it was clear that this hospital would treat those COVID-19 positive patients, who, due to their particular condition, cannot be treated elsewhere. Also, urgent non-covid conditions may be accompanied by a mild, unrecognized or even asymptomatic clinical presentation of the COVID-19 disease, which is why the EC had to be prepared for the influx of such patients, as well. Finally, there are also sporadic arrivals of patients with clear clinical symptoms of the COVID-19 infection, who, nevertheless, mistakenly come to the EC due to their lack of information. The inflow of such patients lays an additional burden on hospital capacity and increases the potential for intrahospital morbidity and mortality , which is why the EC, although a non-covid hospital, had to adapt to dealing with critically ill patients, who may also be highly contagious.
In this paper, we present the ways that the EC-UCCS has shown flexibility and adaptability to the conditions of the pandemic, where no precise protocols had previously been established for acting in these types of situations.
ORGANIZATION OF THE EMERGENCY CENTER IN THE PANDEMIC
The essence of the shift in the operation of the EC is in the precise separation of the patients with epidemiological risk (ER) of COVID-19 or confirmed COVID-19 positive patients from patients without ER, and in their further isolated diagnostics and treatment. This enables the treatment of all critically ill patients regardless of the risk of COVID-19 disease, rationalization of the use of personal protective equipment, as well as the prevention of infection spread to other patients or to health workers.
On the first day that the state of emergency was declared in Serbia, March 15, 2020, the Admissions Triage Facility of Emergency Medicine (ATFEM) was established. It was initially staffed with 7 emergency medicine (EM) specialists, 2 residents, one M.D. and 20 medical technicians. Surgery, internal medicine and anesthesiology residents acted as auxiliary staff, and, as of the month of July, they were joined by emergency medicine specialists from the surrounding Belgrade municipalities. At present, the staff of this facility includes 10 EM specialists, 1 EM resident, and 20 medical technicians, while the auxiliary staff includes 1 EM specialist and 2 EM residents from the Belgrade suburban area. The role of the ATFEM is in the precise triage of the patients with epidemiological risk (ER) of COVID-19 and in their further isolated complete diagnostics and treatment.
The examination room nearest to the triage space (surgical observation room) was reallocated to be used as the admissions triage examination room (ATER) for emergency care, where between 6 and 12 patients can be cared for at any given time. All necessary diagnostic equipment and resources (ECG machine and defibrillator, non-invasive monitoring, portable ventilator, aspirator, portable X-ray and ultrasound machine, central oxygen supply and portable oxygen tanks) were made available only for the care of patients with ER. A separate CT machine was designated only for these patients, while patient transportation to this machine was predefined so as to be performed via an epidemiologically safe route, without contact with other patients.
EPIDEMIOLOGICAL RISK ASSESSMENT
Separating patients with ER from patients without ER is carried out by experienced medical technicians, immediately at patient admission to the EC. In certain situations, assistance is given by specialists or residents of EM. ER assessment includes the epidemiological questionnaire, a short, targeted anamnesis, measurement of body temperature, and the assessment of the patient’s respiratory status.
The questions in the epidemiological questionnaire have changed over time, depending on the current epidemiological situation at the time of their application. Thus, the first questionnaires contained a question related to travel abroad, especially high-risk regions and countries, such as, at the time, Italy, Spain and France. The latest newly introduced questions relate to patient vaccination status and to whether the patient had already had COVID-19 in the past. Any answer that indicates ER in a patient automatically means that the patient is taken to and cared for in the ATER.
Short, targeted anamnesis and/or heteroanamnesis is especially important in critically ill patients, as it quickly provides data on possible symptoms of COVID-19 infection, which further necessitates diagnostics and treatment for these patients in the ATER.
Body temperature is measured with a non-contact thermometer and checked with a thermal imaging camera. Errors and deviations are possible on hot summer days and in patients who had spent a longer period of time in transport, in an ambulance without air-conditioning.
Respiratory status assessment involves measurement of the oxygen saturation level with a pulse oximeter, approximation of the respiration rate, and, in some patients, also quick auscultation by an EM resident or specialist. In this way, patients exhibiting respiratory insufficiency, due to pulmonary edema, chronic bronchitis, COVID-19, or metabolic acidosis, or hyperventilating patients, are separated from the rest of the patients. It is considered that all patients whose respiratory insufficiency is of unclear origin, carry an epidemiological risk.
Patients without ER are referred from triage to the appropriate examination room and are further cared for according to the standard preexisting procedure. In the event that, during the examination of such a patient, it transpires that ER may exist, after all, the patient is returned to the ATER for reevaluation. Patients who are assessed to have ER are further diagnosed and treated in the admissions triage examination room.
CARING FOR PATIENTS WITH EPIDEMIOLOGICAL RISK (ER)
The whole process of triage, examination, and assessment of the need for appropriate diagnostics, initial treatment and other consultative specialist examinations of patients with ER, falls within the responsibilities of emergency medicine specialists. After the patient with ER is processed, the EM specialist, in consultation with the consultants, makes the decision on whether the patient is to receive further in-hospital treatment or whether they are discharged for at-home treatment. In case of confirmed SARS-CoV-2 viral infection (the antigen test has been available since November 2020) or clinical and laboratory presentation of the patient which clearly indicates COVID-19, the patient is transferred from the ATER to an available covid hospital. If, however, in-hospital treatment of a patient with ER is indicated, but clear confirmation of the SARS-CoV-2 viral infection is lacking, the patient is admitted to the EC, into one of the two units designated for isolation – the internal medicine isolation unit (for internal medicine patient admission) or the surgical isolation unit (for the admission of surgical patients). In the hospital isolation units, diagnostics and treatment of such patients is continued until there is definitive confirmation of the SARS-CoV-2 viral infection, in which case the patient is transferred to a covid hospital, or until confirmation that the patient is without epidemiological risk, in which case the patient is admitted to one of the standard hospital wards. In case there is a need for surgical treatment of patients with ER, an operating theater has been designated for only these patients.
Such organization has made possible the rational use of personal protective equipment (PPE), All ATFEM staff, all of the staff in the isolation units, everyone participating in the functioning of the isolation operating theater, and all of the ATER consultants have used the full PPE (in keeping with the Instructions on the Use of Personal Protective Equipment in the Pandemic issued by the Institute of Public Health Dr Milan Jovanović Batut), while the remaining healthcare staff in contact with patients without ER have had at their disposal more basic PPE, depending on the work that they perform.
Between March 15, 2020 and March 15, 2021, a total of 155,000 patients were processed in triage. Of this number, 9,519 patients were with ER and were taken care of in the admissions triage examination room. The greatest number of patients with ER was registered in the period November – December 2020 (Figure 1), which coincides with the third wave of the infection in Serbia (Figure 2). The largest number of confirmed COVID-19 positive patients was registered between November 2020 and March 2021, which correlates with the availability of the antigen tests for the SARS-CoV-2 virus.
The Emergency Center of the UCCS is the hospital with the largest number of treated patients in Serbia (170,000 – 185,000 a year, prior to the pandemic). As opposed to other hospitals, which can limit the influx of patients, by scheduling doctor’s appointments or by postponing scheduled elective surgical procedures, emergency centers must respond to every arrival of critically ill patients and must have an efficient and reliable method of operation in place, for all situations, especially in the pandemic that the entire world is now facing.
Triage is the basis of the proper functioning of every modern emergency center . As a process of categorizing patients into groups of different priority, depending on the degree of severity of their condition or injury , triage was, prior to the pandemic, performed in front of each examination room. Switching from such triage to triage in the pandemic is an essential change in the operation of the EC. The professional medical community recommends that triage in mass disasters (including a pandemic) should be performed by doctors with considerable clinical experience , senior physicians, particularly intensive care and emergency medicine specialists . This was, in fact, applied when the Admissions Triage Facility of Emergency Medicine was formed, placing emergency medicine specialists in the front line.
There are still many unknowns related to the SARSCoV-2 virus and the COVID-19 disease, but it was very quickly established what the only effective course of action in the fight against the disease entails, this being: strict isolation of suspected or confirmed COVID-19 patients, protective measures, and mass testing . Immunization, as a way of limiting infection spread, became available a year after the infection emerged. As it was not possible to test every patient coming to the EC, and since the result of the PCR test, as the most reliable diagnostic test, takes time, it is clear that isolation of patients suspected of the infection was the best way to limit infection spread. This was, in fact, the aim of Emergency Center reorganization, which is why a separate, admissions triage examination room was established. Patients with confirmed COVID-19 infection were referred to covid hospitals, without further delay. What was, and still is, of the utmost importance for the hospital itself, was reducing the spread of the infection within its walls, especially preventing the SARS-CoV-2 virus from entering the intensive care units.
In this way, it was possible to admit all critically ill patients to the EC with no or very little risk of further COVID-19 transmission.
Of course, even in ideal conditions, let alone in the situation that we have found ourselves, flawless triage does not exist. The main drawback of this patient triage system is relying on the clinical presentation and symptoms exhibited by the patient, which, in COVID-19, tend to be very varied and nonspecific. Elevated body temperature, dyspnea, a sore throat, and malaise are not symptoms connected only to the COVID-19 disease, which is why it has often occurred that some of the patients initially cared for in the ATER were eventually diagnosed with heart failure, COPD or asthma exacerbation, bacterial pneumonia, pulmonary embolism, sepsis, etc. Due to constraints in available space, febrile or patients with respiratory insufficiency, who were less suspicious of COVID-19, were not separated from patients with a high suspicion of the infection. The floor area of 50 square meters and the availability of 6 - 12 beds with 6 spots for oxygen supply have proven to be insufficient for treating a large number of patients arriving at the EC at the same time. Other emergency centers have faced a similar problem, as reported by Levy et al., in their study from 2020, which describes the organization of triage at the Sheba Medical Center . Space was limited in the changing and PPE disposal area, as well, which often necessitated improvisation.
Another disadvantage of this type of triage is that it applies only to grouping patients according to ER and not also according to the degree of emergency of the illness or injury. The degree of emergency is still determined separately within each examination room, including the ATER. This is due to the already described lack of space for triage as well as the deficit in staff. However, the Admissions Triage Facility of Emergency Medicine, which was formed to meet the needs arising in the pandemic, and which has been developing and establishing itself over the past year, is already working on implementing new triage protocols for categorizing patients by degree of emergency (the SRTS protocol), which will be implemented immediately after capacities in both staff and space are increased.
Effective triage is of the utmost importance in any situation where there are mass casualties, which includes pandemics, since a great number of patients can very quickly overwhelm the limited available staff and resources. This is why clearly outlined protocols (defined by law) for emergency care in all situations are absolutely necessary, as is supporting infrastructure.