Checklist and Monitoring Tool for Triage of Suspected COVID-19 Cases in Non-US Healthcare Settings

Facility name and type: __________________________________________________________ Date: _________________________________

Assessor’s name: _______________________________________________________ Assessor’s Role: _______________________________

Purpose: To assess the triage process (early identification and separation of patients likely to be infected with SARS-CoV-2, the virus that causes COVID-19) at
healthcare facilities (HCFs) in non-US settings to help prevent spread of COVID-19 to patients and healthcare workers (HCWs). This tool can also be used to
monitor progress of implementing critical components of triage at HCFs.

Instructions:
- Check Yes or No for each item and report items marked No to healthcare facility contact person at the end of each assessment.
- Provide numbers and total numbers in the # and Total # columns for monitoring purposes.
- Calculate percentages for the % column by dividing # by Total # and multiplying by 100.
- Cells shadowed in gray color should be left blank.

Yes No # Total % Assessor Guidance Assessor Comments

#
General
1. A facility phone number for patients to Observe if facility phone number or
call in before presenting to the facility is hotline is available. This should be a
available different phone number from any
national hotlines.
2. All entrances have signs directing Identify all entrances to ensure that
patients with respiratory symptoms to visual signs are posted.
proceed directly to the registration desk Provide # of entrances with signs and
total # of assessed entrances in (#) and
(Total #) columns.
3. Signs on respiratory hygiene and cough Provide # of entrances with signs and
etiquette are posted at all entrances, total # of assessed entrances in (#) and
waiting areas and by the elevators. (Total #) columns.
4. Hand hygiene (HH) stations available at Preferably alcohol-based hand rub
all entrances (ABHR) or sink/bucket system with soap
and water.
Provide # of entrances with HH stations
and total # of assessed entrances in (#)
and (Total #) columns.
Triage area

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 Yes No # Total % Assessor Guidance Assessor Comments
#
1. Separate registration desk for patients
coming in with respiratory symptoms is
available
2. Triage area has:
a. Physical barrier between staff and Observe if a physical barrier is available
patients (e.g., plastic/glass window) at registration desks.
If Yes, provide # of registration desks
with the physical barrier and total # of
assessed desks in (#) and (Total #)
columns.
b. Triage algorithm/questionnaire Observe if the triage
algorithm/questionnaire is available at
registration desks.
If Yes, provide # of desks with the
algorithm/questionnaire and total # of
assessed desks in (#) and (Total #)
columns.
c. Face masks for patients with Observe if face masks are available at
respiratory symptoms registration desks.
If Yes, provide # of desks with face
masks and total # of assessed desks in
(#) and (Total #) columns.
d. Paper tissue for patients with Observe if paper tissues available at
respiratory symptoms registration desks.
If Yes, provide # of desks with paper
tissues and total # of assessed desks in
(#) and (Total #) columns.
e. Hand hygiene station Observe availability of ABHR or
sink/bucket system with soap and
water.
If Yes, provide # of functional hand
hygiene stations in triage area and total
# of assessed stations in (#) and (Total
#) columns.
f. Trash bin with lid Observe if trash bins with lids are
available at registration desks.

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 Yes No # Total % Assessor Guidance Assessor Comments
#
If Yes, provide # of desks with trash bins
with lids available and total # of
assessed desks in (#) and (Total #)
columns.
3. Dedicated clinical staff assigned for Check staff logbooks/duty roster or any
triage other record that documents staff
assignment.
4. Dedicated clinical staff are trained on Ask responsible officer. If Yes, provide #
triage procedures and COVID-19 of trained and total # of clinical staff in
symptoms triage in (#) and (Total #) columns.
5. Area cleaned and disinfected twice a Ask cleaning staff how often they clean
day the area.

6. Area cleaned and disinfected using 0.1% Ask cleaning staff and observe what
chlorine or 70% alcohol they use for cleaning and disinfection.
“Respiratory waiting area”
1. Single rooms with doors are available Observe.
If single rooms are not available, Observe if there is separate area serving
separate area for patients presenting as “respiratory waiting area.”
with acute respiratory symptoms is
available
2. Area is well ventilated Observe. Look for open windows and
closed door or outside area.
3. “Respiratory waiting area” has:
a. Signage indicating “respiratory Observe.
waiting area”
b. Signage on respiratory hygiene and Observe.
cough etiquette is posted in the
“respiratory” waiting area
c. Chairs or benches separated by at Observe.
least 1 m
d. Paper tissues Observe.
e. Hand hygiene station Preferably ABHR or sink/bucket system
with soap and water.
f. Trash bin with lid Observe.
g. Dedicated toilet Observe.

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 Yes No # Total % Assessor Guidance Assessor Comments
#
4. Patients are separated from each other Observe patient placement.
by at least 1 m
5. Area cleaned and disinfected twice a Ask cleaning staff how often they clean
day the area.

6. Area cleaned and disinfected using 0.1% Ask cleaning staff and observe what is
chlorine or 70% alcohol used for cleaning and disinfection.
Triage process
1. Every patient is evaluated for Observe. If No, provide # of patients
respiratory symptoms evaluated for respiratory symptoms and
total # of observed patients in (#) and
(Total #) columns. Duration of the
observation can vary depending on the
availability of assessor time.
2. Triage staff use triage Observe. If No, provide # of patients
algorithm/questionnaire for every evaluated using
patient algorithm/questionnaire and total # of
observed patients in (#) and (Total #)
columns. Duration of the observation
can vary depending on the availability
of time assessor time.
3. Every patient with respiratory symptoms Observe. If No, provide # of patients
is wearing a face mask (or an wearing a face mask (or an alternative)
alternative) and total # of observed patients in (#)
and (Total #) columns. Duration of the
observation can vary depending on the
availability of assessor time.
4. Every patient that meets COVID-19 Observe or question triage personnel if
suspect case definition is immediately triage volume is low. If No, provide # of
isolated/separated into “respiratory patients isolated/separated into
waiting area” “respiratory waiting area” and total # of
observed patients who met case
definition in (#) and (Total #) columns.
Duration of the observation can vary
depending on the availability of
assessor time.

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 Yes No # Total % Assessor Guidance Assessor Comments
#
5. Facility has a policy to limit family Ask to see the facility’s policy limiting
members accompanying patients to the family members to the “respiratory
“respiratory waiting area” waiting area.”
Personal Protective Equipment (PPE)
1. Availability of PPE:
a. Face masks are available Refers to medical mask and not cloth
face covering. See the stock room,
donning and doffing areas.
b. Eye protection is available See the stock room, donning and
doffing areas.
c. Gowns are available See the stock room, donning and
doffing areas.
d. Gloves are available See the stock room, donning and
doffing areas.
e. Heavy duty gloves are available See the stock room, donning and
doffing areas.
f. Boots are available See the stock room, donning and
doffing areas.
2. Staff are trained on proper PPE use, Ask staff and, check training logbooks if
including donning and doffing available.
If Yes, provide # of triage staff trained
on proper PPE use and total # of all staff
in (#) and (Total #) columns.

3. Separate PPE donning and doffing areas are Observe. Donning and doffing areas
available should be separate.
4. Donning and doffing posters (or job aids) Observe. If Yes, provide # of donning
available in PPE donning and doffing areas and doffing areas with posters and total
# of observed donning and doffing
areas in (#) and (Total #) columns.
5. Hand hygiene stations available in PPE Preferably ABHR or sink/bucket system
donning and doffing areas with soap.
If Yes, provide # of donning and doffing
areas with hand hygiene station and
total # of observed donning and doffing
area in (#) and (Total #) columns.
6. HCWs conducting physical evaluations of patients with respiratory symptoms wear:*
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 Yes No # Total % Assessor Guidance Assessor Comments
#
a. Face mask Provide # of observed staff wearing
facemask and total # of staffs observed
in (#) and (Total #) columns.
b. Eye protection (face shield or Provide # of observed staff wearing eye
goggles) protection and total # of staffs observed
in (#) and (Total #) columns.
c. Gloves Provide # of observed staff wearing
gloves and total # of staffs observed in
(#) and (Total #) columns.
d. Gown Provide # of observed staff wearing
gowns and total # of staffs observed in
(#) and (Total #) columns.
7. Environmental service staff in triage, waiting, and examination areas wear:*
a. Face mask Provide # of observed staff wearing face
mask and total # of staffs observed in
(#) and (Total #) columns.
b. Eye protection (if risk of splash from Provide # of observed staff wearing eye
organic material or chemical) protection and total # of staffs observed
in (#) and (Total #) columns.
c. Heavy duty gloves Provide # of observed staff wearing
heavy duty gloves and total # of staffs
observed in (#) and (Total #) columns.
d. Gown Provide # of observed staff wearing
gowns and total # of staffs observed in
(#) and (Total #) columns.
e. Closed-toe shoes or boots Boots can be worn if muddy conditions.
Provide # of observed staff wearing
closed-toe shoes and total # of staffs
observed in (#) and (Total #) columns.
*If possible, complete these sections of the checklist when patients with respiratory symptoms are being evaluated and when environmental service staff are
performing environmental cleaning activities. If not possible, leave blank and question staff on what PPE would be worn during these activities.

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