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Open Access

Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities

Hossein Abdolrahimzadeh Fard, Roham Borazjani, Golnar Sabetian, Zahra Shayan, Shahram Boland Parvaz, Hamid Reza Abbassi, Shiva Aminnia, Maryam Salimi, Shahram Paydar, Ali Taheri Akerdi, Masome Zare, Leila Shayan, Salahaddin Mahmudi-Azer
DOI: 10.1136/tsaco-2021-000726 Published 16 June 2021
Hossein Abdolrahimzadeh Fard
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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  • ORCID record for Hossein Abdolrahimzadeh Fard
Roham Borazjani
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Golnar Sabetian
2Department of Intensive Care Medicine, Trauma Research Center, Shahid Rajaee (Emtiaz) Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Zahra Shayan
3Trauma Research Center, Department of Biostatistic, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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  • ORCID record for Zahra Shayan
Shahram Boland Parvaz
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Hamid Reza Abbassi
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Shiva Aminnia
4Student Research Commiittee, Shiraz University of Medical Sciences, Shiraz, Iran
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Maryam Salimi
4Student Research Commiittee, Shiraz University of Medical Sciences, Shiraz, Iran
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Shahram Paydar
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Ali Taheri Akerdi
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Masome Zare
5Trauma Intensive Care Unite, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Leila Shayan
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Salahaddin Mahmudi-Azer
1Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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    Figure 1

    In our triage model, patients with unstable vital signs, decreased LOC, and in need of life-saving surgeries were considered suspicious for COVID-19 and transferred to special wards after proper resuscitation. In the second step, other patients who did not meet the above criteria, were assessed using their medical histories, epidemiological risk factors (as subjective parameters) and body temperature, respiratory rate (RR), and oxygen saturation (as objective parameters). In the third step, we evaluated individuals according to the obtained laboratory data for evaluating asymptomatic carriers. All other patients were transferred to regular wards and were closely monitored for signs and symptoms of COVID-19. All patients admitted to the ICU wards and those who developed COVID-19 related symptoms were also evaluated during their hospital course using RT-PCR. *A negative result was repeated 4 days later from the lower respiratory tract. **All ICU-admitted patients: evaluated by RT-PCR test. +Two times in 30 min. β, according RSNA classification. CBC, complete blood count; CRP, C-reactive peptide; ESR, erythrocyte sedimentation rate; ICU, intensive care unit; LOC, level of consciousness; RSNA, Radiological Society of North America; RT-PCR, reverse transcription-polymerase chain reaction.

Tables

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  • Table 1

    Definition of suspicious COVID-19 cases, according to WHO, MOHME, and ECDC protocols.

    ProtocolsCase definition
    WHO6Suspected case of SARS-CoV-2 infection:
    A person who meets the clinical AND epidemiological criteria:
    Clinical criteria:
    Acute onset of fever AND cough; OR · Acute onset of ANY THREE OR MORE of the following signs or symptoms: Fever, cough, general weakness/fatigue, headache, myalgia, sore throat, coryza, dyspnea, anorexia/nausea/vomiting, diarrhea, altered mental status.
    Epidemiological criteria:
    Residing or working in an area with high risk of transmission of virus: closed residential settings, humanitarian settings such as camp and camp-like settings for displaced persons; anytime within the 14 days prior to symptom onset; or · Residing or travel to an area with community transmission anytime within the 14 days prior to symptom onset; or · Working in any healthcare setting, including within health facilities or within the community; any time within the 14 days prior to symptom onset.
    Probable case of SARS-CoV-2 infection:
    1. Patient who meets clinical criteria above AND is a contact of a probable or confirmed case, or linked to a COVID-19 cluster.

    2. Suspect case with chest imaging showing findings suggestive of COVID-19 disease.

    3. Person with recent onset of anosmia (loss of smell) or ageusia (loss of taste) in the absence of any other identified cause.

    4. Death, not otherwise explained, in an adult with respiratory distress preceding death AND was a contact of a probable or confirmed case or linked to a COVID-19 cluster.


    Confirmed case of SARS-CoV-2 infection:
    1. Person with a positive Nucleic Acid Amplification Test (NAAT).

    2. Person with a positive SARS-CoV-2 antigen-RDT AND meeting either the probable case definition or suspect criteria A or B.

    3. An asymptomatic person with a positive SARS-CoV-2 antigen-RDT who is a contact of a probable or confirmed case.

    MOHME7Suspicious case
    1. A person with severe febrile respiratory disease who needs to be hospitalized due to fever, cough, etc, and another pathogen to justify his disease’s symptoms is not conceivable.


    Which has at least one of the following characteristics:
    1. History of travel to endemic area within 14 days before the onset of symptoms

    2. Be one of the healthcare providers

    3. Despite appropriate pneumonia treatments, the clinical response is inadequate, and the clinical condition is unusual and unexpected.

    ECDC8Clinical criteria
    Any person with at least one of the following symptoms:
    Cough
    Fever
    Shortness of breath
    Sudden onset of anosmia, ageusia, or dysgeusia
    Diagnostic imaging criteria: Radiological evidence showing lesions compatible with COVID-19
    Laboratory criteria: Detection of COVID-19 nucleic acid in a clinical specimen
    Epidemiological criteria
    At least one of the following epidemiological links:
    Close contact with a confirmed COVID-19 case in the 14 days before the onset of symptoms
    Having been a resident or a staff member, in the 14 days before the onset of symptoms, in a residential institution for vulnerable people where ongoing COVID-19 transmission has been confirmed
    Case classification
    Possible case:
    Any person meeting the clinical criteria
    Probable case:
    Any person meeting the clinical criteria with an epidemiological link
    OR
    Any person meeting the diagnostic criteria
    1. Confirmed case:


    Any person meeting the laboratory criteria
    • COVID-19, coronavirus disease 2019; ECDC, European Centres for Disease Control; MOHME, Iranian Ministry of Health and Medical Education; RDT, rapid diagnostic test; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

  • Table 2

    Demographic data and clinical histories of the suspicious cases (n=132)

    VariablesRT-PCR +ve (n=30)RT-PCR −ve (n=102)P value
    Sex; number (%)
     Male24 (80%)78 (76.5%)–
     Female6 (20%)24 (23.5%)–
     M/F43.250.68
    Nationality; number (%)
     Iranian27 (90%)92 (90.2%)0.97
     Non-Iranian3 (10%)10 (9.8%)
    COVID-19 related history; number (%)
     Close contact7 (23.3%)5 (4.9%)0.002
     Fever10 (33.3%)32 (31.4%)0.83
     Cough6 (20%)11 (10.8%)0.18
     Respiratory distress16 (53.3%)13 (12.7%)<0.001
     Neurological symptoms*5 (16.7%)6 (5.9%)0.06
     Abdominal pain3 (10%)00.01
     Anorexia1 (3.3%)10 (9.8%)0.22
    Past medical history; number (%)
     Cancer2 (6.7%)00.05
     DM3 (10%)6 (5.9%)0.43
     Chronic anemia1 (3.3%)00.22
     Cardiac disease3 (10%)7 (6.9%)0.56
     CKD01 (1%)1.0
     Asthma02 (2%)1.0
     COPD2 (6.7%)00.05
     HTN4 (13.3%)8 (7.8%)0.35
    Hospital course; number (%)
     Intubation11 (36.7%)38 (37.3%)0.95
     Mortality5 (16.7%)11 (10.8%)0.38
     ALOS (days); mean (SD)8.1 (5.6)10.66 (13.66)0.63
    • *Defined as the presence of any of the followings: anosmia, dysgeusia, ageusia.

    • ALOS, average length of hospital stay; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HTN, hypertension; M/F, male to female ratio; RT-PCR, reverse transcription-polymerase chain reaction; −ve, negative; +ve, positive.

  • Table 3

    Diagnostic capability of available protocols in detecting COVID-19 among trauma patients

    ProtocolsRT-PCRSensitivity (%)Specificity (%)
    +ve (n=30)−ve (n=610)
    WHOSuspicious4013.3100
    Non-suspicious26610
    MOHMESuspicious7123.399
    Non-suspicious23609
    ECDC (possible)Suspicious286493.389.5
    Non-suspicious2546
    ECDC (probable)Suspicious7123.399
    Non-suspicious23609
    Our stepwise triage systemSuspicious285993.390.3
    Non-suspicious2551
    • ECDC, European Centre for Disease Control and Prevention; MOHME, Iranian Ministry of Health and Medical Education; RT-PCR, reverse transcription-polymerase chain reaction; +ve, positive; −ve, negative.

  • Table 4

    Frequency of positive clinical and laboratory findings in suspected patients (n=130)

    StagesDetected patients (%)RT-PCR (n=30)
    Stage 154 (40.9%)17 (56.7%)
     1. Decrease in LOC24 (18.2)7 (23.3%)
     2. Unstable hemodynamics32 (24.2)9 (30%)
     3. Life-saving surgery5 (3.8%)1 (3.3%)
     4. Both 1 and 25 (3.8%)3 (10%)
     5. Both 1 and 32 (1.5%)1 (3.3%)
    Stage 240 (30.3%)9 (30%)
     1. History of respiratory symptoms25 (18.9%)
     2. Epidemiological factors9 (6.8%)
     3. Fever20 (15.2%)
     4. RR >2021 (15.9)
     5. Sat O251 (38.6%)
    Stage 314 (10.6%)0 (0%)
     1. Leukocytosis23 (17.4%)
     2. Lymphopenia27 (20.5%)
     3. High ESR13 (9.8%)
     4. High CRP23 (17.4%)
    Stage 422 (16.7%)2 (6.7%)
     1. Fever2 (1.5%)2 (6.7%)
    • CRP, C-reactive peptide; ESR, erythrocyte sedimentation rate; LOC, level of consciousness; RR, respiratory rate; RT-PCR, reverse transcription-polymerase chain reaction.

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Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities
Hossein Abdolrahimzadeh Fard, Roham Borazjani, Golnar Sabetian, Zahra Shayan, Shahram Boland Parvaz, Hamid Reza Abbassi, Shiva Aminnia, Maryam Salimi, Shahram Paydar, Ali Taheri Akerdi, Masome Zare, Leila Shayan, Salahaddin Mahmudi-Azer
Trauma Surg Acute Care Open Jun 2021, 6 (1) e000726; DOI: 10.1136/tsaco-2021-000726

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Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities
Hossein Abdolrahimzadeh Fard, Roham Borazjani, Golnar Sabetian, Zahra Shayan, Shahram Boland Parvaz, Hamid Reza Abbassi, Shiva Aminnia, Maryam Salimi, Shahram Paydar, Ali Taheri Akerdi, Masome Zare, Leila Shayan, Salahaddin Mahmudi-Azer
Trauma Surg Acute Care Open Jun 2021, 6 (1) e000726; DOI: 10.1136/tsaco-2021-000726
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Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities
Hossein Abdolrahimzadeh Fard, Roham Borazjani, Golnar Sabetian, Zahra Shayan, Shahram Boland Parvaz, Hamid Reza Abbassi, Shiva Aminnia, Maryam Salimi, Shahram Paydar, Ali Taheri Akerdi, Masome Zare, Leila Shayan, Salahaddin Mahmudi-Azer
Trauma Surgery & Acute Care Open Jun 2021, 6 (1) e000726; DOI: 10.1136/tsaco-2021-000726
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