When people enter a hospital emergency room with symptoms of COVID-19, they are immediately assessed by a physician who decides if they meet the criteria to be tested and if they should be admitted to the hospital.
This process, called triage, is how doctors decide who gets tested, who is admitted and who receives a ventilator if hospitals become overwhelmed with COVID-19 patients. But in some Oregon hospitals, triage and testing guidelines for COVID-19 patients remain unclear between local medical centers and the Oregon Health Authority (OHA).
In Lane County, 1,540 people have been tested for the novel coronavirus, and others are still fighting to be tested. Because they have limited equipment, hospitals may become overwhelmed, forcing physicians to make difficult decisions on what care patients receive.
Kevin Rau, a media public information officer with the Oregon COVID-19 Joint Information Center, writes in an email to Eugene Weekly that the decision to administer any kind of test or treatment of COVID-19 “lies solely with the treating physician” and that OHA has not issued any recommendation that would change a physician’s treatment of the coronavirus.
Another OHA media public information officer, Phillip Schmidt, writes in an email to EW that OHA’s website provides guidance documents for providers and other public health authorities. The website has general triage protocol documents, but none specific to COVID-19.
Schmidt adds that how a patient is triaged depends on their background and symptoms, which also factors into whether or not a patient receives ventilators.
“We are continuing to urge clinicians to prioritize high risk patients or patients who live in higher risk settings for testing,” Schmidt says.
PeaceHealth Sacred Heart Medical Center University District and Riverbend also say they have procedures for triaging, but the information is not readily available. Anne Williams, a communications specialist, writes in an email to EW that PeaceHealth has triage sites, but gave only a vague idea of guidelines the hospitals use for triaging coronavirus patients.
“As part of PeaceHealth’s preparedness efforts, we developed alternative medicine triage sites for our Eugene and Springfield hospitals,” Williams said.
Williams explained that patients arriving at a PeaceHealth medical center are assessed outside the emergency department before being directed to the emergency room or the designated COVID-19 triage site.
If a patient has respiratory symptoms or a fever, they will be taken to the triage site, where physicians will make the decision whether to test a patient for COVID-19. Then, they will be directed to go home into isolation or brought in to the emergency department for further medical treatment.
“We will follow the medical necessity best practices when determining care for each individual’s health status, giving priority to the most critical patients,” Wlliams says.
When asked further questions about the triage guidelines and how the hospital is preparing in case they are overwhelmed with COVID-19 patients, Williams said she did not have anyone to answer the follow-up questions over the phone and said she believes the email response covered the triage question.
Williams also suggested looking to OHA or the Centers for Disease Control and Prevention(CDC) for more information on triage guidelines, but she did not specify whether PeaceHealth hospitals were following protocols listed by either the state or the federal health authority.
In Portland, Oregon Science and Health University in Portland is treating about 10 COVID-19 patients at the moment and provided documents regarding the hospital’s response to the pandemic, but it also does not list guidelines for how patients are triaged.
Other hospitals offer more transparency when it comes to triage guidelines. The University of Washington Medical Center has an entire webpage of COVID-19 protocols listing in detail what to do and how to decide which patients are prioritized. For example, those who are at higher risk of having complications with the virus are admitted to the hospital before those who may not have underlying conditions. The resources also provides information on policy statements and how the medical center is staying sanitized.
UW Medical Center has several flowcharts for triage that gauge a patient’s medical history along with the supplies available and care needed. No one from UW was available to answer further questions about the guidelines before press time.
If hospitals are unsure of which triage guidelines to follow, the CDC has also produced documents listing ways hospitals should prepare for COVID-19 as well as how to triage patients. It is unclear how local hospitals are determining their triage protocols.
Update: After the story was published, PeaceHealth responded to EW and provided more information and clarification. Here is what they said regarding their triage protocols:
- Hospital capacity: First, it’s important to point out that at the present time and for the foreseeable future, all patients who come to the hospital can and will continue to receive the care they need. There are no shortages of ventilators or beds in Lane County.
- Screenings at ED entrances: All patients are screened at the Emergency Department entrances at each of our four hospitals before they enter. Patients are screened for respiratory symptoms as well as possible COVID-19 from asymptomatic patients. We have separate entrances and rooms to ensure suspected or positive patients are not integrated with other patients.
- Triage to appropriate levels of care: Emergency Departments have a designated triage function where patients undergo a triage assessment by an RN who has been trained in triage assessment. The purpose of triage is to determine who should be seen and in what order. If a patient has a condition defined by law as an “emergency medical condition,” then there are additional requirements that the hospital must meet including a documented medical screening exam (MSE). The triage and MSE requirements have not changed because of COVID-19. Providers are required to evaluate patients and their clinical presentation to determine whether they should be admitted, transferred to a higher level of care or continue healing safely at home.
- Testing criteria: The triage for COVID-19 testing in the Emergency Department is simple. If an individual is deemed sick enough, the provider will order a test. Currently, all patients admitted to PeaceHealth Sacred Heart RiverBend and University District will be tested for COVID-19.
- Crisis triaging: First, it’s important to point out that we are nowhere near reaching a critical surge situation, where crisis triage would be in place. But, if a healthcare system reaches a critical surge status, there is guidance from the state of Oregon that delineates how to triage priority of services to individual patients called the Oregon Crisis Care Guidelines, which all hospitals in Oregon use as guidance. Included in the Oregon Crisis Care Guidelines is an ethical framework. Ethical and standard-of-care guidelines exist for a situation that may reach the level of impact that New York is experiencing. With continued social distancing, compliance with stay-at-home orders and continued practice of good hand washing, Lane County should not need to enact these measures.