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\begin{document}

\title{Smart Check - COVID-19 triage system: evaluation of the impact on the
screening time and identification of clinical manifestations of
SARS-CoV-2 infection in a public health service.}



\author[1]{Fernando Anschau}%
\author[1]{Paulo Worm}%
\author[1]{Luciane  Kopittke}%
\author[2]{Luis Humberto  de Mello Villwock}%
\author[2]{Marcos Luiggi  Lemos Sartori}%
\author[2]{Sandro  Pinheiro}%
\author[2]{Jéferson  Cardoso do Rosário}%
\author[2]{José Francisco  Secorun Inácio}%
\author[2]{Maicon Diogo  Much}%
\author[2]{Eduardo  Marckmann}%
\author[3]{João Ricardo  Nickenig Vissoci}%
\author[2]{Wagner  de Lara Machado}%
\author[2]{Dalton Breno Costa}%
\author[1]{Daniel  Klug}%
\author[1]{Juliane  Martin Prestes}%
\author[2]{Fabiano Hessel }%
\affil[1]{Grupo Hospitalar Conceição}%
\affil[2]{Pontifícia Universidade Católica do Rio Grande do Sul}%
\affil[3]{Duke University}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction: Most patients with COVID-19 have mild or moderate
manifestations, however, there is a wide spectrum of clinical
presentations and even more severe repercussions that require high
diagnostic suspicion. Vital sign acquisition and monitoring are crucial
for detecting and responding to patients with COVID-19. Objective: Thus,
we conducted this study to demonstrate the impact of using a tool called
Smart Check on the triage time of patients with suspected COVID-19 and
to identify the main initial clinical manifestations in these cases.
Methodology: We assessed triage times before and after the use of Smart
Check in 11,466 patients. In this group, we identified 211 patients for
the identification of COVID-19 clinical manifestations in a case-control
analysis. Results: Smart Check was able to decrease the triage time by
33 seconds on average, with 75\% of the exams being performed within 5
minutes, whereas with the usual protocol these steps were performed
within 6 minutes. A range of clinical presentations made up the COVID-19
initial manifestations. Those with the highest frequency were dry cough
(46.8\%), fever (41.3\%), dyspnea (35.8\%), and headache (32.1\%). Loss
of appetite, fever, and ageusia were the manifestations that had a
statistically significant association with the SARS-CoV-2 presence.
Conclusions: Smart Check, a simple clinical evaluation tool, along with
the targeted use of rapid PCR testing, can optimize triage time for
patients with and without COVID-19. In triage centers, a number of
initial signs and symptoms should be cause for SARS-CoV-2 infection
suspicion, in particular the association of respiratory, neurological,
and gastrointestinal manifestations. Keywords: new coronavirus,
COVID-19, triage, clinical manifestations%
\end{abstract}%



\sloppy


Smart Check - COVID-19 triage system: evaluation of the impact on the
screening time and identification of clinical manifestations of
SARS-CoV-2 infection in a public health service.

Abstract:

Introduction: Most patients with COVID-19 have mild or moderate
manifestations, however, there is a wide spectrum of clinical
presentations and even more severe repercussions that require high
diagnostic suspicion. Vital sign acquisition and monitoring are crucial
for detecting and responding to patients with COVID-19. Objective: Thus,
we conducted this study to demonstrate the impact of using a tool called
Smart Check on the triage time of patients with suspected COVID-19 and
to identify the main initial clinical manifestations in these cases.
Methodology: We assessed triage times before and after the use of Smart
Check in 11,466 patients. In this group, we identified 211 patients for
the identification of COVID-19 clinical manifestations in a case-control
analysis. Results: Smart Check was able to decrease the triage time by
33 seconds on average, with 75\% of the exams being performed within 5
minutes, whereas with the usual protocol these steps were performed
within 6 minutes. A range of clinical presentations made up the COVID-19
initial manifestations. Those with the highest frequency were dry cough
(46.8\%), fever (41.3\%), dyspnea (35.8\%), and headache (32.1\%). Loss
of appetite, fever, and ageusia were the manifestations that had a
statistically significant association with the SARS-CoV-2 presence.
Conclusions: Smart Check, a simple clinical evaluation tool, along with
the targeted use of rapid PCR testing, can optimize triage time for
patients with and without COVID-19. In triage centers, a number of
initial signs and symptoms should be cause for SARS-CoV-2 infection
suspicion, in particular the association of respiratory, neurological,
and gastrointestinal manifestations.

Keywords: new coronavirus, COVID-19, triage, clinical manifestations

What's already known about this topic?

It is important to be assertive and quick in identifying cases of
COVID-19;

The main signs and symptoms related to SARS-CoV-2 infection are
referenced in the literature and exhibit a wide variety of clinical
presentations.

What does this article add?

It is important to be assertive and quick in identifying cases of
COVID-19 and the Smart Check tool can assist in this sorting.

The main signs and symptoms related to SARS-CoV-2 infection are
referenced in the literature and exhibit a wide variety of clinical
presentations; here we bring the comparison of these initial signs and
symptoms with those presented in an acute respiratory syndrome or cold
without COVID-19.

.

Introduction:

A new coronavirus (CoV) with a high virulence and capable of infecting
humans (HCoV) is currently holding much of the world's population
hostage.~This virus, known as coronavirus 2, responsible for severe
acute respiratory syndrome (SARS-CoV-2) and coronavirus 2019 (COVID-19)
disease, emerged in late 2019 in China and is currently affecting the
population in more than 210 countries and territories worldwide. ~On
January 30, 2020, the WHO declared it a Public Health Emergency of
International Concern and on April 11, 2020 it was declared a pandemic
(1).~At the time of this article's writing, the WHO estimates that
COVID-19 has been diagnosed in 108,579,352 people from 210 countries
worldwide, causing about 2,396,408 deaths (2). In Brazil there have been
more than 9.8 million cases and about 240,000 deaths (2).

SARS-CoV-2 belongs to a family of viruses that can cause various
symptoms such as pneumonia, fever, difficulty breathing, and pneumonitis
(3).~Clinical manifestations include fever, cough, dyspnea, myalgia,
fatigue, headache, diarrhea, hemoptysis, anosmia, and augesia (4, 5).
Most patients with COVID-19 have mild to moderate symptoms, but
approximately 15\% may progress to critical pneumonia and eventually
develop severe acute respiratory syndrome (SARS), septic shock, multiple
organ failure, and death (4). ~Once the infection sets in, it requires a
high degree of suspicion for a correct diagnosis and the institution of
appropriate therapeutic and restrictive measures due to the enormous
manifestations spectrum.

Vital sign acquisition and monitoring are crucial for detecting and
responding to deteriorating patients, however it is known that during
routine vital sign acquisition and recording, many of the vital sign
records in medical records are incomplete or inconsistent, which can
compromise patient safety (6). Thus, we propose this study to
demonstrate the impact of using a tool called Smart Check on the triage
time of patients with suspected COVID-19 and identify its main clinical
manifestations.

Methodology:

We performed data collection of the time of risk classification and
signs and symptoms of suspected COVID-19 patients at the COVID-19 Triage
Center of the Hospital Nossa Senhora da Concei\selectlanguage{ngerman}ção (HNSC) in Porto
Alegre, in the southern region of Brazil, from June 1 to July 31, 2020.
This triage center has a reception and waiting area, a registration and
triage area, two boxes for exam collection, three consulting rooms, a
stabilization room, and a specific environment for the professionals'
paramentation and de-paramentation. It is open daily, from 8am to 10pm,
with a team of one administrative assistant, three nurses, three
doctors, and four nursing technicians. In addition, it has three
professional hygienists strategically distributed to keep the
environment constantly disinfected. The COVID-19 triage center sees
cases of influenza syndrome and identifies patients with potential
symptoms for COVID-19, referring those with severity signs to the HNSC
emergency room. The time to check vital signs (temperature, blood
pressure, blood saturation, heart and respiratory rates) was considered
as a classification time (table 1). The clinical manifestations were
collected in anamnesis and categorized as listed in table 2.

In the period from July 1 to July 31, 2020, we introduced the Smart
Check tool (multiparametric monitor from the company Toth Life Care ®;
certificate of conformity TÜV 17.1492 dated 04/24/2018), a compact
multiparametric vital signs monitor, into that triage center's care
routine. Through Smart Check there is the possibility to quickly acquire
vital signs (systolic, diastolic, and non-invasive mean arterial
pressure and pulse rate, functional oxygen saturation, body temperature,
blood glucose level) and, in triage mode, store and display the history
of the triages performed. This triage tool communicates with external
devices via\emph{Bluetooth} , it has a bar code reader that allows quick
identification of patients wearing identification bracelets,
and\emph{ethernet} and \emph{wireless} communication with transmission
in HL7 protocol for integration with Hospital Information Systems. In
this study, we used accessory Risk Classification software (SMART RISK®)
for Emergency management.

To determine the impact of Smart Check on COVID-19 triage time, we
conducted a before-and-after type study (n:11,466). To identify the
characteristic clinical manifestations of COVID-19, we developed a
descriptive study and a case-control analysis, where all patients
(n:211), listed at random, who were included underwent real-time
polymerase chain reaction (RT-PCR) testing of nasopharyngeal swab
specimens. Nasopharyngeal swab samples in a single tube of viral
transport medium were obtained under transmission-based precautions from
all patients presenting to the triage center and comprised the
descriptive case-control type study. All biological samples were sealed
and transferred to the laboratory in strict accordance with standard
protocol.

This study was approved by the Research Ethics Committee of the Grupo
Hospitalar Conceição according to opinion n\textsuperscript{o}.
3,968,873 on April 14, 2020 and by the National Research Ethics
Commission of Brazil through opinion n\textsuperscript{o}. 3,990,822 on
April 26, 2020.

Considering an expected sensitivity of 95\%, expected specificity of
80\%, with a margin of error of 10\% and a prevalence of 5.8\% of
COVID-19 in our population, our sample would be estimated at 210
individuals.

Statistical analysis:

We expressed continuous variables as medians and interquartile ranges or
simple intervals, as appropriate. We summarized categorical variables as
counts and percentages, and we calculated associations with Student's
t-test, chi-square, and Mann-Whitney tests. We made no imputation for
missing data. We performed all analyses using SPSS 22.0.

Results:

For the Smart Check tool time analysis, we collected data from 11,466
patients in triage for COVID-19. The group's average age was 41.4 years
(18 to 98 years) and 58.3\% were women. 2,258 (19.7\%) had some
comorbidity, among which hypertension (45.8\%), diabetes mellitus
(20.8\%), asthma (20\%), and heart disease (6.2\%) were the most
frequently reported, followed by obesity and dyslipidemia (4.7\%),
arthritis (4.3\%), smoking (4.2\%), alcoholism (4.2\%), and
hypothyroidism (3.9\%). The average time from symptoms to seeking the
COVID triage center was 4.4 days, with 64\% of cases seeking care within
3 days of the onset of complaints. In table 1 we identified 4,799
patients who underwent COVID-19 triage in the usual manner with a mean
time to risk classification of 4.3 minutes (6 minutes at the 75th
percentile). On the other hand, while using the Smart Check with 6,667
patients, the rating time was 3.74 minutes on average (5 minutes at the
75th percentile).

We performed an analysis of 211 patients, listed at random, who had
diagnostic testing for COVID-19 (RT-PCR by nasopharyngeal swab) to
identify the clinical manifestations that led them to seek triage for
COVID-19. In table 2, we show these signs and symptoms and their
relationship to the presence of SARS-CoV-2 infection. Dry cough (51
cases (46.8\%)), fever (45 cases (41.3\%)), dyspnea (39 cases (35.8\%)),
and headache (35 cases (32.1\%)) were the most frequent signs and
symptoms. Loss of appetite, fever, and ageusia (loss of taste) were the
manifestations that formed a statistically significant association with
the presence of SARS-CoV-2. Dyspnea presented a p value of 0.07 and,
when in conjunction with any of these last 3 clinical manifestations, it
has shown an association with the presence of SARS-CoV-2 infection
(table 3).

Discussion:

One strategy for fighting the COVID-19 pandemic was rapid diagnosis and
care in these specific environments, with segregation of patients with
the disease's most severe and characteristic symptoms. Even in such
environments, patients who seek care for suspected infection may be
exposed to the infection itself if they stay longer than necessary in
triage centers. Nosocomial transmission of COVID-19 puts patients with
other medical problems at risk of serious illness and death.~In this
study, we observed that 19.7\% of patients with suspected COVID-19 had
some comorbidity, which potentially put them at greater risk for serious
illness.

Wake RM et al. demonstrated that from the total of nosocomial SARS-CoV-2
infections, 88\% of patients had shared a ward with a confirmed COVID-19
case.~In that study, the implementation of a triage system combining
clinical evaluation with rapid testing for SARS-CoV-2 facilitated the
cohort so that fewer susceptible patients were exposed to COVID-19 in
shared environments.~With the possibility of future waves of
COVID-19-related hospitalizations, strategies to prevent nosocomial
transmission are essential (7).~With the use of the Smart Check
screening tool there was an average reduction of 33 seconds in the time
it took to classify patients with respiratory syndrome. Considering the
75th percentile of the classification time, we can observe a reduction
of 1 minute in it. Point-of-care diagnostics can complement clinical
evaluation to quickly identify patients with COVID-19 and reduce the
risk of transmission within triage centers and hospitals.

If we take the decrease in the average time for classification with
Smart Check and assess the number of cases classified in the month of
use - July 2020 - it is possible to state that there was a reduction of
62 hours in the classification time/month. Thus, we can state that the
Smart Check tool can contribute to the classification of patients with
suspected Covid-19, bringing celerity to this screening moment. Since
Smart Check quickly characterizes patients' signs and symptoms with
accurate records, we can reduce the risk of transmission and profile
clinical manifestations.

Most patients with COVID-19 exhibit mild to moderate symptoms, but
approximately 15\% progress to critical pneumonia and 5\% eventually
develop acute respiratory distress syndrome, multiple organ failure,
septic shock, and death (4, 8). Once the infection sets in, the spectrum
of clinical presentations ranges from asymptomatic infection to critical
respiratory failure. Most commonly reported symptoms are fever, cough,
myalgia, fatigue, pneumonia, dyspnea, as well as loss of smell and
taste, while less commonly reported symptoms include diarrhea,
hemoptysis, and coryza (4, 5).

We found a range of clinical manifestations that comprised the diagnosis
of SARS-Cov-2 infection, among which dry cough (46.8\% of cases), fever
(41.3\%), dyspnea (35.8\%), and headache (32.1\%) were the most
frequent. However, this clinical presentation is similar to other
respiratory diseases such as influenza, which makes us need some degree
of suspicion for the COVID-19 diagnosis.~Since the clinical
manifestations were collected by direct anamnesis at the time of
screening, we compete with the risk of measurement bias. Patients,
subjects of the research, could not remember related signs or symptoms
or overestimate those who would have them perform COVID-19 screening
tests. Fever seems to be one of the initial events, after 2 to 3 days of
infection, followed by pulmonary manifestations (9). Loss of appetite,
fever, and ageusia (loss of taste) were the manifestations that formed a
statistically significant association with the presence of SARS-CoV-2 in
our study. Dyspnea, when in conjunction with loss of appetite, fever, or
ageusia, has also shown an association with the presence of SARS-CoV-2
infection. The presence of more than one symptom, especially when we
identify the search for care after 3 days of symptoms, has been pointed
out as characteristic of COVID-19, when we can observe, besides
respiratory manifestations (dyspnea, cough), some neurological
manifestations such as ageusia, fatigue, anosmia, headache and myalgia,
and other gastrointestinal manifestations such as loss of appetite,
diarrhea, and abdominal pain (10).

Conclusion:

While social distancing measures can reduce the transmission of COVID-19
in the community, this transmission in triage centers and hospitals
continues to put vulnerable populations at risk of more serious illness
and death. As we identify a new wave of infections and hospital
admissions, prevention of nosocomial transmission remains vitally
important. We demonstrated how a simple clinical evaluation tool - the
Smart Check - along with the targeted use of rapid PCR testing, can
optimize triage time for patients with and without COVID-19. In
addition, a number of early signs and symptoms should be cause for
suspicion of SARS-CoV-2 infection, in particular the association of
respiratory, neurological, and gastrointestinal manifestations.

References:

\begin{enumerate}
\tightlist
\item
  Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. \emph{Acta
  Biomed} 2020;91:157--160.
\item
  World Health Organization. Coronavirus disease 2019 (COVID-19)
  Situation Report -- 98. 2020 {[}cited 2021 Feb 11{]}. https://www.
  who. int/ emergencies/ diseases/ novel- coronavirus- 2019/situation-
  reports/.
\item
  WMHC. Wuhan Municipal Health and Health Commission's Briefingon the
  Current Pneumonia Epidemic Situation in Our City. 2020.http:// wjw.
  wuhan. gov. cn/ front/ web/ showDetail/ 2019123108989. Accessed 1 Feb
  2021.
\item
  Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological
  findings of COVID-19 associated with acute respiratory distress
  syndrome. Lancet Respir Med (2020) 8:420--2. doi:
  10.1016/S2213-2600(20)30076-X.
\item
  He F, Deng Y, Li W. Coronavirus Disease 2019 (COVID-19): What we know?
  J Med Virol (2020) 92:719--25. doi: 10.1002/jmv.25766.
\item
  Stevenson JE, Israelsson J, Nilsson GC, Petersson GI, Bath PA.
  Recording signs of deterioration in acute patients: The documentation
  of vital signs within electronic health records in patients who
  suffered in-hospital cardiac arrest. Health Informatics J.
  2016;22(1):21--33.
\item
  Wake RM, Morgan M, Choi J, Winn S. Reducing nosocomial transmission of
  COVID-19: implementation of a COVID-19 triage system. Clin Med (Lond).
  2020 Sep;20(5):e141-e145. doi: 10.7861/clinmed.2020-0411. Epub 2020
  Aug 11. PMID: 32788160; PMCID: PMC7539706.
\item
  Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features
  of patients infected with 2019 novel coronavirus in Wuhan, China.
  Lancet (2020) 395:497--506. doi: 10.1016/S0140-6736(20)30183-5.
\item
  Awadasseid A, Wu Y, Tanaka Y, Zhang W. Initial success in the
  identification and management of the coronavirus disease 2019
  (COVID-19) indicates human-to-human transmission in Wuhan,
  China.~\emph{Int J Biol Sci} . 2020;16(11):1846-1860. Published 2020
  Apr 6. doi:10.7150/ijbs.45018.
\item
  Hu B, Guo H, Zhou P, Shi ZL. Characteristics of SARS-CoV-2 and
  COVID-19 {[}published online ahead of print, 2020 Oct 6{]}.~\emph{Nat
  Rev Microbiol} . 2020;1-14. doi:10.1038/s41579-020-00459-7.
\end{enumerate}

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