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

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.