Challenges in COVID-19 Pandemic Triaging: An Indian and US Perspective

Abstract

Background/Objectives: The COVID-19 pandemic overwhelmed many health care facilities with patients, leading to an increased risk of potential transmission. Though the disease process was identical, the triaging system was unique at different sites, without a unified system for emergency department triaging globally. Proper implementation of pre-screening and triaging is of paramount importance in tertiary care settings to prevent nosocomial spread of infection. Methods: Each country has its own triage guidelines and Infection, Prevention, and Control policies developed by its health ministry and may face significant challenges in implementing them. Triage guidelines followed by two tertiary care hospitals in Detroit, United States of America and Manipal, India are compared during the early phases of the COVID-19 pandemic. Results: This paper offers a unique perspective of the challenges experienced with the hospital triage practices and provides solutions to address them. The future trajectory of COVID-19 epidemiology in both countries will be determined by the adherence to best practices in Infection Prevention and Control and triage protocols. The healthcare facility triage algorithm is constantly evolving in both settings as new evidence is being added to hospital epidemiology and infection prevention practices. Conclusions: Training healthcare workers on new triage protocols is required. It is critical for infectious disease doctors, clinical microbiologists, hospital epidemiologists, and Infection Prevention and Control (IPC) staff to collaborate with clinicians, nurses, and other ancillary staff in order to successfully implement the triage protocols. Developing and modifying guidelines for cleaning hospital triage areas and providing high throughput for patient care are also important lessons learned. Usage of face shields and the quality of Personal Protective Equipment (PPE) should be ensured for all healthcare workers (HCWs). Resilient staff and resilient hospital infrastructure are crucial for a sustainable response to future pandemics.

1. Introduction

The novel coronavirus SARS-CoV-2 (COVID-19) pandemic, a highly transmissible virus spread via respiratory droplets, overwhelmed health care systems and economies worldwide in 2019. As the COVID-19 pandemic continued, the USA and India often led in the number of cases worldwide [1]. A key part of controlling this pandemic was to curb the spread of COVID-19 in these two countries. Thus, a comparison between the Detroit and Manipal COVID-19 triage systems would help countries facing similar challenges moving forward and identify solutions for patient care during pandemics in urban and semi-urban settings, respectively. Not only are these locations different with respect to size/population, but also in terms of culture, climate, and living conditions. These differences may have informed triage systems during the COVID-19 pandemic. This manuscript not only reflects upon how the triage system could improve in either country, but it can also help provide context for better preparation in years to come, especially in locations that are similar to the two discussed.

1.1. COVID-19 in Detroit, Michigan, USA

As of 31 August 2021, a total of 110,202 confirmed COVID-19 cases and 2636 deaths were reported in Detroit and Wayne County since March 2020 [2]. The number of COVID-19 cases first peaked at the end of March 2020 and beginning of April 2020. Since then, there was a gradual decline, with subsequent surges in the fall of 2020 (Figure 1) and again in March 2021 [3].

1.2. COVID-19 in Udupi District, Karnataka, India

As of 31 August 2021, Udupi District of Karnataka, India recorded a total 73,899 COVID-19 cases with 459 deaths [4]. The COVID-19 pandemic in Udupi started in the month of March 2020, predominantly affecting the age group of 30–40 (26.6%) year olds [4]. India’s initial response and lockdown appeared to reduce spread of COVID-19 and help flatten the epidemic curve during the first wave, including in Udupi District (Figure 1). The surge of the second wave started in mid-April 2021 and plateaued. Even though more hospitals were ready to manage COVID-19 patients, based on their experience during the first wave, the number of moderate-to-severe cases requiring ICU care overwhelmed the healthcare system. The deadly second wave was likely driven by the new variants of concern, including the delta variant (B.1.617.2), aided by human behavioral factors contributing to complacency and lack of nonpharmaceutical interventions.

The delta variant (B.1.617.2) of the SARS-CoV-2 virus contributed to the increase in cases in India, and this strain of the virus then spread globally [5].

The delta variant of COVID-19 was originally found in India in December 2020, and was at one point the most common strain, having overtaken the alpha variant, known initially as the UK’s Kent variant (B.1.1.7) [6,7]. This had emerged as a major variant during the second wave of COVID-19 in India [8,9,10]. Though the 28-day case fatality rate remained low (0.1%), the emergence of this variant was of grave concern because there was evidence that those with the delta variant had twice the risk of transmission and greater risk of hospitalization [11,12]. There was also concern about vaccine effectiveness against delta variant; a study demonstrated that in sera taken from individuals who had recovered from delta variant the virus was more resistant to neutralizing antibodies [13]. This raised complications in terms of preventing spread.

2. Materials and Methods

For this observational study, information about the practices in triaging and workflow were gathered through interviews with members of the healthcare teams at both the hospitals in Manipal, India and Detroit, USA who played a direct role in establishing the ED triage system in these respective locations. Open-ended questions were asked to gain knowledge from the representatives of the healthcare providers. The ED director, hospital administrators, infectious disease (ID) physicians, COVID-19 doctors and nurses, hospital epidemiologist, and infection prevention specialist were all interviewed to gain a better understanding of the challenges encountered during COVID-19 triaging in the ED. No other additional individuals were interviewed in this process. Hospital triage manuals, protocols, and guidelines were obtained from the hospital’s ID director in Detroit, as well as the chairman of the HICC (Hospital Infection Control Committee) at KMC Hospital, Manipal. National guidelines for triaging and Infection Prevention and Control practices for the COVID-19 pandemic were accessed from the National Center for Disease Control (NCDC); the Ministry of Health and Family Welfare (MoHFW), Government of India, COVID-19 Information portal, and Government of Karnataka websites; and from the US Center for Disease Control and Prevention [14,15,16]. This information was gathered in the early stages of the pandemic in 2020, and was then assembled, reviewed, and discussed with either experts from HICC or the director of ID in Detroit, USA. A detailed discussion with the expert panel took place, which covered the changes in triage protocol that occurred during the first and second waves of the COVID-19 pandemic. The triage workflow diagrams that were used in Manipal and Wayne County, as well as the differences and similarities between the guidelines followed during the first wave and second wave of the pandemic, were examined and analyzed. COVID-19 data and statistics were obtained from free, authentic online resources, and public use datasets were collected from websites such as worldometers, covid19india, and the Detroit Health Department to compare the burden of the COVID-19 pandemic in the US and India [3,17,18]. Demographic data of Udupi District was obtained from the Indian Census 2011 produced by the Government of India, and data for Wayne County was obtained from the United States Census Bureau and World Bank [19,20,21,22]. The map (Figure 1) was created using ArcGIS, and the epidemic curve for the COVID-19 pandemic in Udupi District and Wayne County was created using Microsoft Excel (Version 2021, Microsoft Corporation, sourced in Manipal, India).

The main outcomes of interest in this observational study were both triage algorithms established in Detroit, USA, compared to Manipal, India; no quantitative data was obtained. Potential confounders include ED systems adjusting triage protocols as the pandemic continued without changes in the algorithm and more due to clinical gestalt, overcrowding, or resource limitations, for example. In such cases, accurate comparison would not be obtained, as the subjective data differs from reality. However, since the triage algorithms were informed by local experts, this was less likely to happen.

3. Results

3.1. COVID-19 Triage in a Detroit Tertiary Hospital

As the COVID-19 pandemic escalated in March 2020, a triage algorithm was quickly adopted to protect public health as local healthcare facilities became overwhelmed with COVID-19 patients (Figure 2). At entry to the ED, all patients were screened for respiratory symptoms including fever, cough, and shortness of breath, as well as any history of travel to COVID-19 endemic areas like China, Japan, Korea, Italy, Iran, Hong Kong, Washington State, or California. Subsequently, as cases increased, travel screening was discontinued from triage protocol. If a patient had respiratory symptoms or positive travel history, a respiratory mask was provided to patient, as were hand hygiene instructions, and the patient was moved to a closed-door room in the ED. Healthcare workers (HCWs) would then call the patient under investigation (PUI) via cell phone or walkie-talkie, and if COVID-19 criteria were met, the patient would then proceed to obtain Flu A/B Rapid and RSV testing. If the influenza test results were negative, the PUI was then transferred to an ED negative-pressure airborne isolation room, if available. The Special Pathogen Pager personnel were then consulted to discuss the presumed COVID-19 diagnosis and the Local Public Health Department would be alerted. Early in the pandemic, due to the lack of testing availability, the Michigan Department of Health and Human Services determined whether the PUI should be tested for COVID-19.

If testing was recommended, a nasopharyngeal or oropharyngeal swab was obtained, along with a sputum sample if the patient had a cough. Finally, if the patient was medically stable, they were discharged to home isolation with continued monitoring by public health officials. However, if the patient was not medically stable, they were admitted to a negative-pressure room using a predetermined physical pathway.

In the initial two surges during the spring and fall of 2020, further adjustments by ED staff and patient triage were instituted. First, tents were set up outside of the ED to limit the contact between COVID-19-positive patients and HCWs or other patients. Also, testing was conducted in vehicles and only select patients were instructed to enter the ED, as deemed medically necessary by medical personnel. Tents continued to be used during the third surge and subsequently were not needed post-delta-variant surge.

3.2. Challenges Faced in Detroit

During the pandemic, continuous changes in guidelines and recommendations of the CDC required staff and facility managers to make rapid adjustments to new patient screening and assessment protocols accordingly. For instance, when the WHO advised that the public wear masks in June of 2020, the ED had to ensure triage protocols were compliant with the new mandate [24].

Another challenge experienced by HCWs across the country during the peak of the pandemic in 2020 was the lack of sufficient PPE. In June 2020, the demand for PPE was 100 times greater than usual and cost 20 times more than in the pre-pandemic period [25]. Although implementation of universal masking was integral to public health and safety, it contributed to this shortage of PPE for healthcare providers. The CDC and National Institute for Occupational Safety and Health (NIOSH) recommend an N95 respirator be used once during conventional capacity [25]. However, given the PPE crisis, HCWs reused respirator PPE for several days until they were soiled. Later on, the CDC recommended that in crisis situations when supplies of N95 masks were running low, HCWs could consider reusing the N95 for a maximum of five donnings per individual before discarding [26].

Front-line workers, including those in EDs, were faced with the increasing prevalence of genetic variants of SARS-CoV-2 which demonstrated increased transmissibility and severity of disease. The CDC monitored data pertaining to variants via the National SARS-CoV-2 Strain Surveillance Program to better understand the evolution of the virus at that time [27].

3.3. COVID-19 Triage in a Manipal Tertiary Hospital

In Manipal, the pre-screening and triage facility was set up near the entrance of the main hospital building in the parking lot. Details of people entering the hospital were collected for contact-tracing purposes. The COVID-19 help desk provided assistance to identify infected patients and redirect them to trained clinical staff who further evaluated the patient. The pre-screening and triage algorithm followed in the Manipal tertiary hospital is depicted in Figure 3. The patients entering the fever clinic were classified as either non-suspect, suspect, or positive.

The hospital had a dedicated healthcare team coordinating the clinical triage. All patients entering the hospital were screened for COVID-19 using standard WHO case definitions at the first point they accessed the health care system [28]. At the entry point, patients were triaged based on fever and respiratory symptoms. If patients had a fever (>38 °C) or history of fever and one sign or symptom of respiratory disease (e.g., cough or shortness of breath), they were provided a medical mask and placed in a single person room (or an isolation room if available), separated from the rest of the patients in the waiting area. Throat or nasopharyngeal swabs were collected from patients with respiratory symptoms as per protocol and tested. Acuity-based triage was the standard method used for identifying patients who required immediate medical intervention and those who could safely wait [29]. Patients were admitted to appropriate wards for treatment and discharged home after recovery. In addition, contact and droplet precautions were strictly implemented for all the patients as well as the HCWs.

3.4. National Guidelines for COVID-19 Triage in India

The Indian Council of Medical Research (ICMR) as well as the National Centre for Disease Control (NCDC), Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, had provided guidelines for COVID-19 patient triaging [29]. Karnataka was the first state to introduce fever clinics and swab collection centers [30]. At this time, there were three types of healthcare facilities dedicated for the management of COVID-19: the COVID-19 Care Centre (CCC) managed asymptomatic patients; COVID-19 Health Centers (DCHCs) managed mild to moderately symptomatic patients; and dedicated COVID-19 hospitals (DCHs) managed patients with severe symptoms. DCHCs acted as Health Screening Centers (HSCs) and performed testing as per the testing policy of the state government. The mechanism of triaging and decision-making for identification of the appropriate COVID-19 dedicated facility for providing care to COVID-19 patients was performed in DCHCs.

According to the national guidelines for Infection Prevention and Control (IPC) for COVID-19, the first step was the establishment of the Hospital Infection Control Committee (HICC) at hospitals [29]. The HICC was chaired by a senior administrator and a team representing all relevant departments. The hospital’s HICC and Department of Infectious Diseases were responsible for implementing training and evaluating the effectiveness of the IPC program in the facility, including triaging [29]. The goal was to reduce the transmission of hospital-acquired infections as well as enhance the safety of patients, visitors, and HCWs.

Multiple COVID-19 treatment facilities were required during the time of community transmission and the “hub and spoke” model of referral was recommended by the Government of India. Not all the hospitals had facilities to treat severe COVID-19, and the Primary Health Centers (PHCs) under the government health system in India had triage within temporary isolation rooms. The severe patients were referred to the nearest dedicated COVID-19 hospital from facilities such as PHCs, which offered limited services [29].

3.5. Challenges Faced in Manipal

During the COVID-19 pandemic, the triage protocols were changed and modified frequently as more research studies evolved the understanding of transmission and treatment. HCWs and patients were at constant risk of nosocomial transmission and clear communication was critical to provide the best care to patients and ensure their safety. As the initial surge of the COVID-19 pandemic escalated, there was a shortage of health care capacity as doctors and nurses also got infected or quarantined. Due to a diversion of medical resources for the management of COVID-19 cases, other patients seeking care for non-COVID-19 diseases faced difficulties in obtaining adequate care. A high influx of patients and their relatives to the hospital caused significant overcrowding due to family members standing outside the triage area, creating further challenges. In addition, anxiety and fear among hospital HCWs rose dramatically during the first wave in 2020. Doctors and nurses faced tremendous physical and mental exhaustion as well as ongoing challenges in the allocation of resources.

Along with PPE, widely available testing and quick turnover of the results would be essential to make rapid decisions regarding quarantine or isolation protocols and could be applicable for any pandemic. Newer screening infrastructure enabling both rapid and sensitive testing were needed to avoid ongoing transmission of the SARS-CoV-2 virus, especially in asymptomatic carriers. Rapid antigen tests at the time were only able to detect the virus when an individual was symptomatic, near or at the peak of infection, making them far less sensitive than the gold standard polymerase chain reaction (PCR) tests, which can detect small amounts of viral genetic material [31]. In addition, comprehensive infection control training needed to be provided to all staff in the ED to ensure everyone involved was well versed with screening methodologies. These training sessions should have been repeated as needed with every new update to the protocol. Finally, the pandemic revealed that the ED infrastructure was more prepared for trauma situations than for infectious diseases and there needed to be increased resilience to address any new external shocks to the system. As such, it is important to develop a predetermined protocol for any similar circumstances in the future. This includes a flexible infrastructure, allowing space for adaptability, and a larger team-based approach that permits group-based, rather than individual, decision-making.

Table 1. Challenges faced by HCWs in the USA and India during various waves of the COVID-19 pandemic.

Challenges	USA			India
	First Wave Spring 2020	Second Wave Fall 2020	Third Wave Spring 2021	First Wave Fall 2020	Second Wave Spring 2021
Triage Process	Travel history screening conducted, Michigan Department of Health and Human Services provided advice	Travel history screening removed Limited negative pressure room availability	Screening heavily regulated by presenting symptoms Vaccination status asked	Travel history collected Triage process carried out in accordance with national guidelines	Travel history screening removed No change in triage practices Overwhelming number of cases
Major Strains		B.1.1.7	B.1.1.7	B.1.1.7	B.1.617 and B.1.1.7
Medical supplies and human resources
PPE/N95 mask	Short supply and the lack of a centralized system for reusing PPE	Short supply and higher peak	Greater availability and ability to discard PPE daily	High cost and short supply. Poor quality and reduced number of vendors supplying PPE	Short supply
Medications	No short supply	No short supply	No short supply	No short supply	Significant short supply (increased severe cases and indiscriminate use)
Oxygen supply	No short supply	No short supply	No short supply	No short supply	Significant short supply (increased severe cases and poor logistics)
Bed occupancy	Mostly ICU and some wards	Wards and ICUs	More wards and less in ICUs	Mostly in wards and ICUs	Mostly ICU and some wards
Healthcare personnel	Fear among HCWs due to unknown nature of pandemic	Fear due to increasing cases	Higher rates of vaccination among HCWs	Fear among the HCWs	High positivity among HCWs
Clinical Management and Laboratory testing
Case load	Both ICU and ward patients were admitted, with ICU case load being the highest	Both ICU and ward patients were admitted	Decreasing as more of the country is vaccinated	Both ICU and ward patients were admitted	ICU case load has increased
Clinical presentation	Classic symptoms of COVID-19	Classic and atypical symptoms of COVID-19	Classic and atypical symptoms of COVID-19	Classic symptoms of COVID-19	Atypical symptoms, rapid progression, younger population, increasing cases of delta variants
Treatment	Guidelines were based on weak evidence. As a result, a cocktail of medications were used	Guidelines were based on better evidence	Guidelines were based on strong evidence	Guidelines were based on weak evidence. As a result, a cocktail of medications were used	Guidelines were based on better evidence (severe short supply of drugs)
Vaccination	Not available	Not available	All HCWs eligible, some hesitancy due to side-effect concerns in the long term	Not available	All HCWs were eligible; however, vaccine hesitancy was a challenge
Vaccine Platforms	Monovalent mRNA vaccines			Viral vector vaccines and inactivated vaccines
Laboratories	PCR test results within a week because tests were sent to central labs	PCR test results within several days	Greater availability of PCR tests with less than 24-hour turnaround time		2555 laboratories were recognized by ICMR to test COVID-19 (as on 21st May 2021)
Mental Health
Fear and anxiety	High due to unknown disease and possible risk to HCWs, as well as family members	Decreasing due to increased preparedness and greater evidence-based knowledge/medicine	Decreasing due to increasing vaccination rates among HCWs	Fear and anxiety was a challenge, with COVID-19 being a new disease	Marginally less because of better understanding of the disease and better vaccination status. But, delta variant mortality created some panic
Social stigma	Not present	Not present	Not present	Significantly higher	Violence against HCWs
Physician burnout	Long working hours and uncertainty of the health risks; peak exhaustion	Long working hours for several months, leading to exhaustion	Taking the pandemic in stride, accepting it as the new norm, elective procedures reinstated	Long working hours	Exhausted due to heavy case load
Health education	Difficult to navigate around misinformation regarding COVID-19	Higher education among HCWs and public	Higher education among HCWs and public trying to persuade people to get vaccinated	Challenging to educate HCWs and the patients	Reorientation required
Government guidelines	Changing constantly, adjusting to the climate at the time	More established guidelines	Less frequent change in guidelines	Changing constantly	More adapted to local needs

Abbreviations: HCWs, Healthcare workers; PPE, Personal Protective Equipment; ICU, Intensive Care Unit; ICMR, Indian Council of Medical Research.

further demonstrates the similarities and differences between the USA and India as the COVID-19 pandemic progressed with respect to medical supplies and human resources, clinical management and laboratory testing, mental health, health education, and government guidelines.

4. Discussion

The comparison between Detroit and Manipal’s triage systems is useful as it offers a perspective into the unique challenges experienced around the world and how they were respectively overcome. Other comparative data in the context of ED triage has not been particularly well studied, making this observational study increasingly valuable.

State health authorities should have a strategy for surge capacity to manage moderate-to-severe COVID-19 patients in order to tackle new pandemics. The surge capacity can be achieved by enhancing the infrastructure and trained human resources in the public hospitals in partnership with the private healthcare sector with a plan to continuously educate healthcare facilities regarding triaging and management of COVID-19.

Several lessons were learned from this comparison, including that healthcare facilities should continue meticulous screening and triaging protocols until the pandemic at hand ends. Patients and their contacts entering the hospital should be clinically screened and asked to follow COVID-19-appropriate behavior, as they could have been asymptomatic. Neither triage algorithms initially included known COVID-19 contact history; however, information was gathered in the event that contact tracing needed to be performed. The screening area should have clear directions to the triage area, an algorithm for triage, a screening questionnaire, meticulous documentation, PPE, hand hygiene equipment, IEC materials and IPC posters, infrared thermometers, pulse oximeters to measure oxygen saturation, waste bins and access to cleaning/disinfection, and signage in the local language for patients with specific symptoms to alert HCWs.

Through first-hand experience in the ED triage systems, it can be seen that, in both Detroit and Manipal, it was crucial to maintain a unidirectional flow of patients and hospital staff and ensure droplet and contact precautions for all HCWs. Routine cleaning of the environment and proper disposal of PPE is critical in the triage areas. Healthcare professionals, patients, and visitors should be regularly updated about infection control practices for COVID-19 or future pandemics. Universal precautions such as masking, respiratory etiquette, hand hygiene, and social distancing play an important role in preventing the spread of this infection. HCWs should be trained on proper donning and doffing of PPE. Placing patients with respiratory illnesses in a dedicated waiting area with adequate ventilation and droplet and contact precaution is crucial. Telemedicine can be leveraged to reduce the risk of exposure for patients who do not require face-to-face consultations. Finally, hospital infrastructure should be optimized to respond to major pandemics, as well as natural/environmental disasters, as occurred in the USA due to Hurricane Ida.

Additionally, in both Detroit and Manipal, especially during surges of COVID-19, prescreening was often conducted in tents or ED parking lots. While this can be an effective with triage, it may also lead to additional crowding around the ED facility. As such, repurposing of existing infrastructure may be a useful tool that could be utilized. Similar to how high schools, libraries, and convention centers are often used for large-scale vaccination, these spaces can also be utilized for prescreening to limit the traffic near ED facilities and make for quicker work flow.

Print, electronic, and social media should regularly educate the general public on COVID-19 prevention strategies and also raise awareness of the hospital triaging protocols. As already documented, universal vaccination against COVID-19 plays an important role in preventing symptomatic infections and curtailing transmission. All HCWs should be strongly encouraged to be vaccinated. In the USA, a multi-society statement was published calling for vaccination of HCWs as a condition of employment [32].

As the COVID-19 pandemic continued, HCWs and healthcare facilities and systems needed to adapt by building resilient HCWs as well as resilient systems. The processes and procedures to develop and train a resilient healthcare system will require a multifaceted approach. This will require a multi-stakeholder review and assessment of not only human resources and capital, but also supplies, equipment, agile information systems, and financial resources.

Limitations

Of note, in both Detroit and Manipal, initial triage largely involved respiratory symptom and fever screening to determine next steps. Although this may be sufficient to distinguish between mild and severe cases of potential COVID-19, the triage algorithms do not necessarily include key symptomology such as anosmia and ageusia largely associated with COVID-19. As these findings came to the forefront, triage algorithms could have been adjusted to include them in the screening process for positive predictive value. However, interestingly, these symptoms are not included in the WHO’s suspected case definition [27].

Furthermore, the lack of availability of point-of-care COVID-19 testing in the early stages of the COVID-19 pandemic could certainly have led to delays in care and contact tracing. Send-out laboratory testing may be limited, especially in rural settings due to turn around time, and thus point-of-care testing integration would be crucial in surge events if feasible.

Although comparing and contrasting triage algorithms from such diverse settings offers valuable insight, the lack of quantitative data with regards to patient outcomes with each triage system, wait times, COVID-19 testing results, and more are unavailable. The solely descriptive comparison provided in this paper offers a subjective, rather than factual, analysis and limits the generalizability of the lessons learnt as they are specific to tertiary hospital systems in Detroit and Manipal.

5. Conclusions

The COVID-19 pandemic revealed that, though there were unique challenges and several differences in the approach to the triaging of the pandemic in these two very different regions, there were also several similarities. Establishing a central agency to help with the creation of a framework for triaging and conducting similar processes during the times of global disasters is critical. Of note, given the current climate changes and impact on human health, healthcare facilities will need to promote the building of resilience for both HCWs as well as healthcare care systems to respond to external shocks to systems. The Emergency Operation Center staff of healthcare facilities will need to be trained to respond to simultaneous biological threats as well as climate- and weather-related disasters, as noted with the impact of Hurricane Ida in USA. Moving forward, there needs to be creation of global networks that will aid in the implementation of standardized protocols along with adapting to the evolving science on novel pathogens and vaccines.