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Forward Triage: Inside the Hartford Hospital Emergency Department

April 03, 2020

Only two weeks ago, a team of doctors, nurses and members of the facilities and operations teams gathered to design and activate a forward triage unit at Hartford Hospital. In this space, patients can be screened and evaluated for COVID-19 before entering the hospital.

When the unit opened to patients the first week of April, it became  a game-changer for the hospital’s Emergency Department during the COVID-19 crisis.

Dr. Fred Tilden, Medical Director of Hartford Hospital’s Emergency Department, calls the initiative “social-distancing, ED-style.” By sorting for COVID-19 and then triaging patients outside the brick-and-mortar emergency department, they are keeping the non-COVID patients inside safe from infection.

As the coronavirus crept closer to Hartford, the team mobilized quickly, doing site surveys to determine the best course of action, weighing the pros and cons of various structures. Working with FIP Construction, physicians and used initial crude drawings and refined the vision for the unit.

The result is four modular units joined together to make a structure 32 feet by 40 feet. Two adjoining tents are the first entry point for patients. Walk-up patients enter one tent and patients arriving by ambulances visit the other.

The patient is met by a triage nurse, who gathers information about COVID-19 symptoms. People with symptoms enter the trailer for further evaluation. If the nurse doesn’t think a case is COVID-related, the patient is instructed to begin the regular triage process in the hospital’s emergency department. Patients who arrive by ambulance who are very ill with COVID-19 symptoms need a higher level of care and are brought into the hospital emergency department, where they are sequestered from non-COVID-19 patients.

Bimal Patel, President of Hartford Hospital, has high praise for the team that produced the triage unit.

“Not only is our team bravely and compassionately caring for patients during this crisis,” he said, “they have demonstrated great ingenuity and an amazing ability to adapt under pressure to implement policies and programs to safely and efficiently deliver care during the pandemic.”

The unit has 17 individual patient bays and four workstations on wheels, Wi-Fi and C-MED communications. Two nurses and two providers – any combination of doctor, nurse practitioner or physician assistant – are fully garbed in personal protective equipment and evaluate upon arrival.

The goal of forward triage is to determine as early as possible whether a patient is suspected of having COVID-19. Patients who are evaluated but not in need of ED treatment will be released with at-home care instructions, including quarantining.

The unit will be put to the test during a surge, when COVID-19 patient arrivals increase considerably. Dr. Tilden says keeping COVID-19 patients away from non-infected patients is key.

“Forward triage will take these patients out of the mix in the ER,” he said. “They are patients who are not so ill and do not need testing, who generally can be followed by their primary physician. Most will be discharged from the trailer and sent home.”

Tilden commended the team: “The Department of Public Health called this the best unit of its kind in Connecticut. We got there because we had the right group of motivated people to make it happen. Emergency departments do a lot of drills, but the reality is that you can’t drill for this sort of thing. But we are nimble and we do know how to ramp it up. The COVID-19 epidemic is different but it’s in our wheelhouse.”

Hartford HealthCare is opening forward triage units across the state. St. Vincent’s Medical Center in Bridgeport launched the pilot on March 18, with similar units scheduled at the following locations:

Not feeling well? Call your healthcare provider for guidance and try to avoid going directly to an emergency department or urgent care center, as this could increase the chances of the disease spreading.

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