(ed. note: Emergency Room (ER) and Emergency Department (ED) are used interchangeably. While many facilities call themselves ED to reflect scope of service, ER is still the more recognizable term.)

Triage and Screening

One problem for ER’s will be to keep folk who do not have flu from catching it while in the ER from folk that do.

In the situation where you already know that flu is active in the US (but not yet your area), I submit the following suggestion for review and revision by the wiki community.

Flu screening for type A flu (without specificity as to H3N2? (is that the current human strain or are we on H1N1 since 1978 vs H5N1?) can be done in 10 minutes with an in-office ‘rapid’ test for influenza, commonly used in urgent care clinics.

Given this technology, upon identifying the first case of flu in an ER, in the condition of knowing bird flu is present in the US, I suggest immediately creating an outdoor (or heated tent?) triage desk for all except the critical-care trauma/imminent code patients (who go directly to more controllable environments in any case and can be tested once stabilized, then the room sterilized). This outdoor triage could be staffed by your lowest level caregivers (medical students with an experienced RN supervising?) and would have no task except to test *every* prospective patient for flu before they enter the doors of the ER. Those positive for flu could be segregated. Family members would be advised to go home until called to pick up the patient because someone came in with the flu and you don’t yet know if it was the human or bird variety. Minors get one parent who can come in, who must also be tested.

Its expensive and requires a lot of rapid flu tests to be kept in inventory. However for the first day or two of an outbreak it could help reduce viral spread long enough for ‘fever centers’ to be established to deal with all flu cases. I’m thinking this would go on for maybe a single day while a flu center is established, if the first 12 hours disclose more infections. If no further folk test flu positive in 12 hours then I’d go back to normal operations till the next flu case comes in. I’m thinking if you had any spread in the region that you’d get your patients arriving in clumps, and so a 12 hour window is probably long enough a sample to determine if you identified an isolated case or the tip of the iceberg.

After the first day or two, anyone with flu-like symptoms would be sent to the fever center with the presumptive diagnosis of flu and they would not get a flu test. Those who do not have flu symptoms and have another presenting complaint would be screened for flu (pre-symptom) before entering the ER for as long as the supply of flu tests remained.

  • Tasmania: “A sports centre would be converted to a fever clinic under emergency plans to respond to any influenza pandemic. The local plan was launched at Kingborough Sports Centre, Kingston, yesterday by Kingborough Council and director of public health Roscoe Taylor. Under the plan, the fever clinic would sort cases according to the urgency of treatment required. A centrepiece of the plan, which will be a blueprint for detailed plans in all local government areas, was to protect the big acute hospitals from patients unless they had severe medical problems.

A further issue is the shrinking number of ERs, at least in the US, even as visits skyrocket. See CDC Press release from May, 2005.

Possible Scenarios

  • Educated white collar professional has just returned from a business trip to Jakarta. Doesn’t remember any contact with ill people, felt fine last night and OK this AM but at noon has a 40 degree C fever, rales, and rapidly dropping BP. Starts to show slight cyanosis as he’s being evaluated.

  • A relapsing middle-aged cancer patient due for his regular chemo, with a mental disorder, say Tourette, running a 40°C fever, deep dry cough, accompanied by his teenage daughter who looks exhausted and stupid. He then tells you his young second wife is in bed at home and does not breathe well, and that she is hot and delirious too. And the two younger children are 5 and 7 and misbehaved, one being a diagnosed hyperactive child for whom they have run out of Ritalin. They had to walk three miles across the fields as there is no petrol to put in the car, and it took them the best part of 2 hours to arrive to the hospital.

  • Four strong guys are carrying a young woman on a makeshift cart. They tell you they found her just outside town, near some woods. She’s prostrate and shivering beneath the blanket, you hear belaboured breathing and grumbling rattles. The guys are telling you they think she was attacked. On lifting the blanket, you see all her clothing in disarray, bruises are starting to show up on some parts of her partially bare body. She has lacerations on her chest, red marks around her neck, drying blood traces, scratches, etc. One of the guys tells you she has muttered unintelligible words. Another tells you that the walk to the hospital is making him feel tired, you touch his forehead and it’s “boiling hot”. Just at that moment he starts a great big coughing fit all over everybody around.

  • The fire brigade has just contacted the local hospital, asking the ER to be ready to take in patients from a retirement home that’s just burning right now. They tell you this home looked after very ill old patients, some of whom are already being treated for respiratory ailments in addition to their usual bad health with various cardiac people, kidney patients, Alzheimer, well the lot. The nurses/ancillary staff is coming too to help, some of whom do show signs of being unwell. The fire brigade has managed to put them into coaches, the most severe lying in the central aisle, with drips hung on the coach’s ceiling luggage racks. Some patients families have learnt about the fire and are coming to the hospital, completely distraught and demanding that their loved oldies be taken care of. Some of these relatives look of a violent disposition, others start insulting the triage staff.

  • One of the patients presenting himself at the hospital, say 25 years old, looks like he’s been on the road, has all classical signs of China Plague, is unkempt, looks like he’s had a good dose of pot, stinks alcohol, and addition to all this, when the triage staff examine him, it is found he has a bad case of scabies.

  • Two young children, aged 8 and 9, looking physically well, are coming running, asking you to send someone at home because their parents are sick, passing blood through their noses, not moving much, their parents don’t talk, but they have been coughing a lot in the previous hours. They tell you they tried to treat them, but they need a doctor. Their neighbours are either dead, or they don’t open their doors. They’re scared, their hands are dirty with blood they tried to wipe, and with food they tried to put in their parents’ mouths. They tell you there is no heating at home, they did not manage to light a fire in the bedroom with the branches they picked from bushes in the garden, they tried to boil water on the electricity which is still on, but they spilled the last of the water. The pet guinea-pig is running loose in the house and the cat is sitting on Mom’s chest. There is hardly any food left, except some flour and tinned beans, but they did not manage to open the tin and all they could do was pour some leftover juice in the flour and push it in their parents’ mouths.

  • A young woman comes to you screaming and howling, dragging a young half dressed three-year old child by the arm, which arm is already bruising with her grip. She has obviously lost her head, and also, she says she just miscarried at 7 months, she’s bleeding a little over her wet skirt, she has disordered abrupt movements. She just cannot stop screaming except when she has a fit of coughing and spitting. She swears at all people around. She’s red hot and perspiring. You have few neuroleptics, the gynecologist or obstetrician is in a protected ward in another part of the hospital. In the midst of all going on, you hear her screaming that she’s a diabetic type I also.

  • There’s a priest who says that most people you turn away to head for their homes are going to die, and he wants to make a tent right in front of the triage area where these people can have the last rites before they go home. The priest is fearless and will not wear protective equipment. He wants to see any person, sick or not, for confession and recommending their souls to a higher being.

Triage and Screening - Documents

  • This US document, Providing Mass Medical Care with Scarce Resources: A Community Planning Guide contains extensive elements of thinking about Triage of Patients. See: “Palliative Care” (Chapter VII, page 102) and an “Influenza Pandemic Case Study” (Chapter VIII, page 118).
Page last modified on November 21, 2006, at 12:39 PM by FrenchieGirl