Speaker : Dr. Faiza Rasheed Public Health Specialist General Directorate of Health Affairs Riyadh Region Lecture held on Meeqat General Hospital,Madinah

1. MERS – CoV
Guidelines &
Respiratory Triage
Speaker : Dr. Faiza Rasheed
Public Health Specialist
General Directorate of Health Affairs Riyadh Region
Lecture held on Meeqat General Hospital Madinah

2. CONTENTS
 Introduction
 GDIPC – MOH MERS – CoV cases (Jan – June 2019)
 Flow of patients from ER (Administrative Interventions)
 Visual Triage for rapid identification of patients with ARI symptoms
 Visual Triage Station
 Visual Triage Checklist
 Respiratory Triage Clinic
 Respiratory Waiting Area
 MERS – CoV Case Definition
 Transmission Based Precautions
 Patient Placement
 Management of exposure in health care facilities
 Summary

3. INTRODUCTION
.
1: MERS - CoV is an emerging viral infection poses a significant public health threat.
2: Middle East Respiratory Syndrome (MERS) is a viral respiratory disease caused by a
novel coronavirus (Middle East Respiratory Syndrome Coronavirus, or MERS - CoV) that
was first identified in Saudi Arabia in 2012.
3: Typical MERS-CoV symptoms include fever, cough and shortness of breath. Pneumonia
is common, but not always present. Approximately 35% of reported patients with MERS-
CoV have died.
4: Zoonotic in nature transmitted from camels to humans.
5: Primary conduit for person to person viral transmission (direct or indirect) are
respiratory secretions released through sneezing and coughing.

5. MIDDLE EAST RESPIRATORY SYNDROME
CORONAVIRUS –
GUIDELINES FOR HEALTHCARE
PROFESSIONALS
VERSION 5.1 MAY 21, 2018

6. FLOW OF PATIENTS FROM ER

7. VISUAL TRIAGE FOR RAPID IDENTIFICATION OF PATIENTS
WITH ACUTE RESPIRATORY ILLNESS(ARI)
 Visual triage should be used for early identification of all patients with ARI
in the Emergency Room, Dialysis unit, and Clinics.
 Visual triage station should be placed at the entry point of the healthcare
facility:
 Emergency room entrance
 Dialysis unit entrance
 OPD Clinics
 Attended by a nurse or nurse assistant who is trained on suspicion of
MERS as per a checklist form with Scoring mechanism.
 Identified ARI patients should be asked to wear a surgical mask and
perform hand hygiene.
 They should be evaluated immediately in an area separate from other
patients.

8. VISUAL TRIAGE STATIONS
VISUAL TRIAGE
SCORING CHECKLIST
24/7 at ER &
other
entrances

10. VISUAL ALERTS FOR ENTRANCES
 Post visual
alerts at the
entrance to
outpatient
facilities (ER
and clinics).
 Instruct
patients and
companions )
to inform
HCWs of S/S of
ARI.
 Practice
Respiratory
Hygiene/Cough
Etiquette.

11. RESPIRATORY TRIAGE CLINIC
 All Cases with Triage score of 4 & above are directed to Respiratory
Triage Clinic.
 Single room (Negative pressure / HEPA filter)
 Vital Signs & clinical evaluation for MERS – CoV case definition.
 If meets the case definition, patient should be should be transferred to
Negative pressure Isolation room or single room with HEPA Filter
where patient will be tested for MERS – CoV.

12. RESPIRATORY WAITING AREA
If ARI patients
cannot be
evaluated
immediately,
they should
wait in a
waiting area
dedicated for
the ARI
patients with
spatial
separation of
at least 1 m
between each
ARI
Patient.

13. CONFIRMED CASE
A Confirmed case is defined as a suspected case with
laboratory confirmation of MERS - CoV infection.

15. KEY POINTS
 1 All suspected cases should have samples collected for MERS-CoV testing
(nasopharyngeal swabs or sputum, and when intubated, lower respiratory secretions)
 2 Adult is defined as > 14 years old
 3 Chronic renal failure and congestive heart failure patients may exhibit fever and
presence of fluid overload may mask the radiological features of pneumonia
 4 Exposure is defined as a contact within 1.5 meters with a confirmed MERS-CoV
patient.
 5Exposure to camels include: Direct physical contact with camels or their
surroundings (milking and handling excreta are especially risky), drinking raw camel
milk or other unpasteurized products derived from camel milk, and handling raw
camel meat.
 6Indirect contact include casual contact with camel places like visiting camel market
or farms without direct physical contact with camels, living with a household member
who had direct contact with camels.

16. PATIENT PLACEMENT
1. Patients with suspected or confirmed MERS-CoV infection who are not
critically ill should be placed in single patient rooms in an area that is clearly
segregated from other patient-care areas. A portable HEPA filter could be used
and placed according to the manufacturer recommendations.
2. Critically ill patients with suspected or confirmed MERS-CoV infection
should be placed in Airborne Infection Isolation Rooms (Negative Pressure
Rooms), if available.
3. When negative pressure rooms are not available, the patients should be placed in
adequately ventilated private rooms with a portable HEPA filter and is placed
according to the manufacturer recommendations.
4. When single rooms are not available, suspected or confirmed MERS-CoV patients
should be placed with other patients of the same diagnosis (cohorting). If this is
not possible, place patient beds at least 1.2 meters apart.

17. TRANSMISSION BASED PRECAUTIONS
 MERS - CoV is believed to spread between humans mainly through contact and
respiratory droplets.
 However, transmission through small particle droplet nuclei (aerosols) may occur.
 For patients with suspected, or confirmed MERS-CoV infection who are NOT
CRITICALLY ILL, Standard, Contact, and Droplet precautions are
recommended.
 For patients who are CRITICALLY ILL, Standard, Contact, and Airborne
precautions are recommended due to the high likelihood of requiring aerosol-
generating procedures.
An aerosol-generating procedure (AGP) is defined as any medical procedure that can
induce the production of aerosols of various sizes, including small (< 5 microns)
particles. AGPs includes bronchoscopy, sputum induction, intubation and extubation,
cardiopulmonary resuscitation, open suctioning of airways,

18. MANAGEMENT OF EXPOSURE TO MERS-COV IN
HEALTHCARE FACILITIES
 Healthcare workers exposed to a MERS-CoV case:
Healthcare facilities should identify and trace all health care workers who had
protected (proper use of PPE) or unprotected (without wearing PPE or PPE used
improperly) exposure to patients with suspected, or confirmed MERS-CoV infection.
1. Asymptomatic healthcare workers WITH protected exposure OR unprotected low
risk exposure (more than 1.5 meters of the patient)
2. Healthcare workers who had unprotected high-risk exposure (within 1.5 meters of the patient)
or have suggestive symptoms regardless of exposure type
 Patients exposed to a MERS-CoV case:
1. Patients can be exposed to MERS-CoV patients prior to diagnosis or due to the failure
of implementing recommended isolation precautions.
2: Patients sharing the same room (any setting e.g. ward with shared beds, open ICU,
open emergency unit, etc.) with a confirmed case of MERS-CoV for at least 30
minutes:

19. SUMMARY
 Implementation of visual triage is crucial for early
identification & isolation of suspected cases.
 Frontline ER doctors have key role in applying criteria for
diagnosis of suspected cases based on updated guidelines
in order to avoid delay in suspicion for MERS – CoV or
missed cases.
 Infection Control is everybody’s responsibility to ensure
safety of patients, staff and visitors.

20. THANK YOU