Tool 7 – Clinical Triage Guidelines During Pandemic Critical Resource Stage
Draft 3/13/07
Clinical Triage Guidelines during Pandemic Critical Resources Stage
Notes:
1. Influenza symptoms: High fever (T > 38) plus sore throat, cough or shortness of breath. Other symptoms: weakness, malaise, myalgias, chills, headache, nasal congestion, and (sometimes) abdominal symptoms.
2. Pandemic flu triage protocol must consider:
Available resources: vital signs, examination, pulse oximetry
Patient: wears respiratory mask on presentation
Personnel: respiratory and universal precautions
Evaluation: age, living conditions, functional status, sick contacts
Other comorbid medical conditions
A. Adults and children >10 years of age AND 25 kg (55 pounds): modified pneumonia severity index (PSI) calculation
Characteristic Points assigned
Highest risk age group(s) (to be determined) +10
Significant co-morbid illness[1] +10
Physical exam
Altered mental status +20
Respirations >30 +20
Systolic BP<90 +20
Pulse >125 +20
Room air pulse oximetry <92% +20
(1) Admission to hospital: Score 50 or
a. Toxic appearance or rapid decompensation (especially important in adolescents and in pregnant women)
b. Significant hypoxia – O2 saturation in room air < 88%
(2) Admission to Influenza Care Center:[2]
a. Score 50 and no hospital beds available, OR
b. Score < 50 and needs closer monitoring and nursing care (for example, IV fluids, IV antibiotics, etc.), OR
c. Score < 50 and unable to care for self or return if symptoms worsen.
(3) Discharge to home:
a. Score 50 with poor prognosis and unlikely to benefit from hospitalization, or
b. Score < 50 and able to care for self or has caregiver, and able to return if symptoms worsen.
B. Children under 10 yrs of age:
Indications for hospital admission include any of the following
a. Fever and age < 3 months
b. Significant tachypnea
c. Hypoxia on pulse oximetry
d. Chest retractions, cyanosis, intermittent apnea, nasal flaring
e. Toxic appearance
The plan is currently pending for how to provide care to children who meet criteria for hospital admission when no pediatric hospital beds are available.
2
[1] For purposes of these triage guidelines, significant co-morbid illness would include any of the following:
· Pregnancy
· Asthma requiring daily use of medications, or symptomatic at presentation,
· Chronic lung disease, requiring oxygen or medications, or symptomatic at presentation,
· Hemodynamically significant congenital heart disease,
· Heart failure,
· HIV infection with CD4 count < 200,
· Patients on systemic steroid therapy equivalent to prednisone 15 mg/day for 1 month,
· Severe rheumatological or autoimmune diseases,
· Other immunocompromising conditions likely to result in life-threatening complications,
· Renal patients requiring dialysis,
· Cancer, currently on chemotherapy or radiation therapy,
· Severe anemia with hemoglobin concentration < 10 gm/dl,
· Hemoglobinopathies, such as sickle cell disease or thalassemia,
· Chronic neurological disorders affecting the muscles of respiration, such as spinal cord injuries, spastic quadriplegia, muscular dystrophy, etc.
[2] Persons with the following conditions can not be accommodated at an Influenza Care Center (due to staffing ratios, equipment, or supply limitations), regardless of their score:
· Age < 10 yrs
· Weight > 300 lbs (ICC cot weight limit is 300 lbs)
· Asthma exacerbation or other condition requiring respiratory support
· Congenital heart disease on oxygen
· Unstable angina
· Pregnant with condition requiring hospital care or within one week of due date
· Cirrhosis with ascites
· Chronic renal failure on dialysis
· Acute immunosuppressing condition (acute leukemia, s/p bone marrow transplant, etc)
· Sickle cell disease
· HIV with CD4 < 200
· Mental status precluding care with minimal staffing (dementia, psychosis, delirium, suicidality, homocidality)
· Acute alcohol or drug withdrawal, or on methadone maintenance
· Severe mobility impairment (from neuromuscular disorder or otherwise)