Screening and Triage at Intake

Key Concepts

To limit the spread of COVID-19, it is important to promptly identify, separate, and ensure ill patients are wearing a cloth face covering (source control). Recent studies indicate that people who are infected but do not have symptoms likely also play a role in the spread of COVID-19. For this reason, source control measures should be implemented for everyone in the facility, regardless of symptoms. It is also important to maintain a safe distance (at least 6 feet) between both patients and staff, as much as possible.

More information about source control measures, including when facemasks versus cloth face coverings could be used is available here.

Screening patients before they enter the facility:

• Reduces exposures for other patients and healthcare personnel
• Helps prevent the spread of disease within the facility
• Helps ensure personal protective equipment (PPE) is used effectively

Screen Patients for COVID-19 at Intake

Facilities should make sure triage procedures are compliant with HIPAA guidance and consider a multi-step screening process to ensure patients with symptoms are not missed prior to entering the treatment area. While the process for screening depends on facility layout and staffing, the general steps include:

• Advise patients to check their temperature at home before leaving for their dialysis session. Advise them they should put on a cloth face covering, regardless of symptoms, before leaving their home.
• Instruct patients to notify the facility before arriving if they have fever or symptoms of COVID-19
  • Consider using automated communications to remind patients about reporting symptoms (e.g., texts on their dialysis day or robocalls)
  • If they have symptoms, they should discuss them with a healthcare provider before arriving
    • Advanced notice gives the facility time to prepare for the patient’s arrival or, if indicated based on symptoms, to refer them to a higher level of care
• Ask all patients upon entry to the facility if they have a fever or symptoms consistent with COVID-19.
  • Place a staff member near all entrances (outdoors if weather and facility layout permit), or in the waiting room area, to ensure patients are screened for symptoms and fever before entering the treatment floor
  • If patients are not already wearing a cloth face covering, provide a cloth face covering or a facemask (if supplies allow)
• Send patients to the appropriate waiting areas, which should be organized to divide patients with symptoms from patients without symptoms
  • Separate patients by at least 6 feet, and the area for patients with symptoms should be at least 6 feet away from the area for patients without symptoms
• Post alerts such as signs and posters at clinic entrances and in strategic places around the facility with instructions for patients with fever or symptoms of respiratory infection

Considerations for Staff

Facilities should make sure staff members who are screening patients remain 6 feet away from the patient until screening determines a patient is symptom-free and afebrile (temperature ascertained by patient report or active temperature monitoring). If there is widespread community transmission of COVID-19, facilities can consider instituting active temperature monitoring by having a staff member check the patient’s temperature immediately upon arrival at the door and when the patient is first asked about symptoms.

• Screening staff should wear a facemask or cloth face covering (for source control) but do not need to wear PPE if they are separated from patients by a physical barrier such as a glass or plastic window. Screening staff should make these interactions as brief as possible by limiting the interaction to screening questions only.
• If a staff member must be within 6 feet of a patient, they should use appropriate PPE, including an N95 or higher-level respirator (or facemask if a respirator is not available), gloves, and, eye protection. A gown could be considered if extensive contact with the patients is anticipated. Cloth face coverings are not considered PPE and should not be worn by HCP when PPE is indicated.

After a Patient is Screened

If patient reports not having symptoms and no fever is detected (by patient report or on active temperature monitoring if performed), they can be directed to a waiting room area for patients without symptoms. Patients should still wear their cloth face covering and maintain a safe distance (at least 6 feet) from each other whenever possible.

If patient needs urgent care, immediately notify healthcare provider for further clinical management and to determine if a higher level of care is needed.

If patient reports having symptoms or fever is detected (by patient report or on active temperature monitoring if performed):

• Provide patient with a cloth face covering or facemask (if not already wearing one from home and supplies allow), educate them on proper placement of mask, and instruct them to leave it on while they are in the facility
• Direct patient to remain 6 feet away from other patients and staff not wearing appropriate PPE. Maintain this separation by:
  • Designating a part of the waiting area (taking into account layout and size of waiting area) that is separate from the other patients by at least 6 feet
    OR
  • Designating a separate waiting area in another room for symptomatic patients, if layout permits
    OR
  • Allowing symptomatic patients to wait in a personal vehicle or outside the facility until their treatment time, if medically stable
• Notify direct patient care staff of the presence of a symptomatic patient
• Take the patient back to the appropriate treatment area as soon as possible
• Immediately after departure of the symptomatic patient from waiting area, disinfect surfaces that were within 6 feet of the symptomatic patient
  • Items that cannot be disinfected, such as magazines and other paper materials, should remain with the patient or be discarded
  • This is in addition to the regular (frequent) baseline cleaning and disinfection process that should be occurring for the entire waiting area

Definitions:
Cloth face covering: Textile (cloth) covers that are intended to keep the person wearing one from spreading respiratory secretions when talking, sneezing, or coughing. They are not PPE and it is uncertain whether cloth face coverings protect the wearer. Guidance on design, use, and maintenance of cloth face coverings is available.

Facemask: Facemasks are PPE and are often referred to as surgical masks or procedure masks. Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.