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Frontline health care workers, including physicians, are at high risk of contracting coronavirus disease (COVID-19) owing to their exposure to patients suspected of having COVID-19.
The aim of this study was to evaluate the benefits and feasibility of a double triage and telemedicine protocol in improving infection control in the emergency department (ED).
In this retrospective study, we recruited patients aged ≥20 years referred to the ED of the National Taiwan University Hospital between March 1 and April 30, 2020. A double triage and telemedicine protocol was developed to triage suggested COVID-19 cases and minimize health workers’ exposure to this disease. We categorized patients attending video interviews into a telemedicine group and patients experiencing face-to-face interviews into a conventional group. A questionnaire was used to assess how patients perceived the quality of the interviews and their communication with physicians as well as perceptions of stress, discrimination, and privacy. Each question was evaluated using a 5-point Likert scale. Physicians’ total exposure time and total evaluation time were treated as primary outcomes, and the mean scores of the questions were treated as secondary outcomes.
The final sample included 198 patients, including 93 cases (47.0%) in the telemedicine group and 105 cases (53.0%) in the conventional group. The total exposure time in the telemedicine group was significantly shorter than that in the conventional group (4.7 minutes vs 8.9 minutes,
The implementation of the double triage and telemedicine protocol in the ED during the COVID-19 pandemic has high potential to improve infection control.
Since the beginning of the 20th century, various infectious diseases have repeatedly threatened both population health and health care systems worldwide. The rapid growth of international transportation has paved the way for the transmission of infectious diseases across regions, including severe acute respiratory syndrome (SARS), H1N1 influenza, Middle Eastern respiratory syndrome (MERS), and Ebola virus [
During the response to the COVID-19 pandemic, a considerable number of frontline health care workers have been infected with the new coronavirus. In China, the first COVID-19 case among health care workers was reported on January 20, 2020; as of February 11, 2020, health care workers represented 1716/44,672 (3.8%) of all patients with laboratory-confirmed COVID-19 and 247/1668 (14.8%) of critical cases, with 5 deaths [
Emergency departments (EDs) are at the frontline of the health care response to the COVID-19 pandemic and are responsible for rapid and safe triage of patients and isolation of suspected patients with COVID-19 from patients with noninfectious diseases. Therefore, establishing a screening protocol for patients with suspected COVID-19 and isolating them in a separate, well-ventilated space for clinical interviews can facilitate infection control [
Telemedicine can be defined broadly as the use of telecommunications technology to provide medical information and services [
As of May 2, 2020, Taiwan had 432 confirmed COVID-19 cases, and a total of 63,713 patients were tested. Nearly 97% of the Taiwanese population have access to the health care system and are covered by the National Health Insurance; hence, they can readily access health care [
The National Taiwan University Hospital (NTUH) is a 2700-bed teaching hospital that provides both primary and tertiary care. It was designated as a COVID-19 response hospital in Taiwan. From March to April 2020, the number of average daily visits was 211, and the number of average daily visits to the NTUH ED by patients posing a risk of COVID-19 transmission was 12.
We conducted a retrospective study using prospectively collected data of patients who visited the ED between March 1 and April 30, 2020. The study was approved by the Institutional Review Board of the NTUH (REC No. 202003043RINA), and the requirement to obtain informed consent was waived.
In the course of the health care response to the COVID-19 pandemic, we developed a double triage and telemedicine protocol for the ED to manage patients suspected of having COVID-19. The protocol comprised two major components: 1) streamlining and diverting patient inflow using a double triage method and 2) evaluating suspected COVID-19 patients using telemedicine (
Regarding the double triage method, the first triage (Triage 1) was set up outside the entrance of the ED to screen patients based on their likelihood of posing a risk of COVID-19 transmission. The double triage helped examine the patients’ history of travel, occupation, contact, and cluster (TOCC) based on the guidelines issued by the Taiwan Centers for Disease Control and available epidemiological data [
The health care workers in the COVID-19 emergency clinic were instructed to don appropriate PPE, including an N95 face mask, a waterproof gown, a non-disposable face shield, a hair cap, shoe sleeves, and two layers of gloves, when working in the clinic. A nurse was assigned to verify the appropriateness of the PPE and record the times of donning PPE, doffing PPE, and entering and exiting the clinic. In the COVID-19 emergency clinic, physicians performed face-to-face interviews with patients before performing physical examinations and collecting specimens for COVID-19 reverse transcription–polymerase chain reaction (RT-PCR) tests. In our study, patients evaluated using face-to-face interviews were assigned to the conventional group.
To improve infection control in the ED, we established a COVID-19 telemedicine team of nine attending physicians and four senior residents and provided them with training in the telemedicine interview system (TIS) on March 27, 2020. On April 1, 2020, the TIS was introduced in the COVID-19 emergency clinic (
The total exposure time was defined as the time that a physician remained in contact with a patient during their face-to-face interview. The total evaluation time was defined as the time the physician took to interview and assess the patient and collect specimens for laboratory testing. Both these time intervals were prospectively recorded.
Furthermore, we conducted a survey using a 10-item questionnaire in both groups upon completion of the clinical evaluation. The questionnaire was modified from a questionnaire for evaluating patient satisfaction with telemedicine [
Diagram of the double triage and telemedicine protocol. COVID-19: coronavirus disease; ED: emergency department; TOCC: travel, occupation, contact, and cluster history; TTAS: Taiwan Triage and Acuity Scale.
We included adult patients aged ≥20 years who were diverted to our COVID-19 emergency clinic during the study period. Patients who refused TIS in the telemedicine group were excluded from this study. Furthermore, to control the confounding effect of evaluation by different physicians, patients not evaluated by the COVID-19 telemedicine team were excluded from the analysis dataset.
The primary outcomes of interest included physicians’ total exposure time and total evaluation time. The secondary outcomes were the mean scores of the questionnaire survey used to evaluate the double triage and telemedicine protocol.
Descriptive statistics are presented as mean (SD) for continuous variables, and the intergroup differences in means were analyzed using the independent sample
We initially enrolled 707 adult ED patients in the study, of whom 203 (28.7%) were excluded from the study because of high TTAS levels (I and II). Before implementing the TIS, 342 patients were interviewed, of whom 237 (69.3%) were not interviewed by the telemedicine team. After the introduction of the TIS, 162 patients were interviewed, including 1 patient who refused the TIS and 68 others who were not interviewed by the telemedicine team. We also excluded all patients who were not interviewed by the telemedicine team and those who refused the TIS. Finally, 93 patients were included in the telemedicine group for analysis, compared with 105 patients in the conventional group (
The clinical characteristics of the patients are presented in
The mean age showed no significant difference between the telemedicine group and the conventional group (mean 39.8 years, SD 17.1, vs mean 38.4 years, SD 25.1;
Flowchart of patient disposition. COVID-19: coronavirus disease; ED: emergency department; TTAS: Taiwan Triage and Acuity Scale.
Baseline demographic and clinical characteristics of patients in the telemedicine and conventional groups (N=198).
Characteristic | Telemedicine group (n=93) | Conventional group (n=105) | ||
Age (years), mean (SD) | 39.8 (17.1) | 38.4 (25.1) | .65 | |
Male gender, n (%) | 41 (44.1) | 44 (41.9) | .76 | |
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Married | 22 (23.7) | 21 (20.0) |
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Single, divorced, or widowed | 71 (76.3) | 84 (80.0) |
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Senior high school or lower | 31 (33.3) | 16 (15.2) |
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University or higher | 62 (66.7) | 89 (84.8) |
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Travel | 26 (28.0) | 56 (53.3) | <.001 |
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Occupation | 36 (38.7) | 41 (39.1) | .96 |
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Contact | 19 (20.4) | 25 (23.8) | .57 |
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Cluster | 1 (1.1) | 2 (1.9) | >.999 |
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Triage level III | 76 (81.7) | 58 (55.2) |
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Triage level IV or V | 17 (18.3) | 47 (44.8) |
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Diabetes | 8 (8.6) | 2 (1.9) | .05 |
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Malignancy | 4 (4.3) | 1 (1.0) | .19 |
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Chronic renal disease | 4 (4.3) | 0 (0.0) | .05 |
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Chronic liver disease | 2 (2.2) | 1 (1.0) | .60 |
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Cardiovascular diseases | 8 (8.6) | 1 (1.0) | .01 |
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COPDc or asthma | 3 (3.2) | 5 (4.8) | .73 |
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Cerebrovascular accident | 1 (1.1) | 0 (0.0) | .47 |
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Hypertension | 11 (11.8) | 6 (5.7) | .13 |
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Attending physician | 54 (58.1) | 88 (83.8) |
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Resident | 39 (41.9) | 17 (16.2) |
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Admission | 20 (21.5) | 35 (33.3) |
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Discharge | 73 (78.5) | 70 (66.7) |
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72-hour ED revisit,d n (%) | 2 (2.7) | 0 (0.0) | .50 |
aTOCC: travel/occupation/contact/cluster.
bED: emergency department.
cCOPD: chronic obstructive pulmonary disease.
dHospitalized patients are excluded.
The total exposure time and total evaluation time were compared to estimate the benefits of the implementation of the double triage and telemedicine protocol (
Box plot of the differences in the total exposure time and the total evaluation time between the telemedicine and conventional groups.
Estimates of the crude and adjusted mean differences in the total evaluation time and total exposure time in minutes between the telemedicine and conventional groups.
Outcome | Telemedicine group |
Conventional group |
Mean difference estimatea | 95% CI | |||||
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Crude | Adjustedb | Crude | Adjusted | Crude | Adjusted | |
Total exposure time | 4.7 (2.4) | 8.9 (4.3) | –4.2 | –4.6 | –5.2 to –3.2 | –5.7 to –3.5 | <.001 | <.001 | |
Total evaluation time | 12.2 (3.5) | 8.9 (4.3) | 3.3 | 2.8 | 2.2 to 4.4 | 1.6 to 4.0 | <.001 | <.001 |
aThe conventional group estimate was subtracted from the telemedicine group estimate.
bThe model was adjusted for age, gender, triage level, educational status, and primary care physician level.
Numbers of respondents by point of the 5-point Likert scale and mean scores of the telemedicine and conventional groups.
Survey question | Telemedicine group (n=82)a | Conventional group (n=96)b | |||||||||||||
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Responsed, n (%) | Mean score | Response, n (%) |
Mean score |
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1 | 2 | 3 | 4 | 5 |
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1 | 2 | 3 | 4 | 5 |
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1. I am satisfied with the visit. | 1 (1) | 0 (0) | 3 (4) | 20 (24) | 58 (71) | 4.6 | 0 (0) | 0 (0) | 3 (3) | 29 (30) | 60 (63) | 4.5 | .33 | ||
2. I had enough time to tell the doctor about what happened to me. | 1 (1) | 0 (0) | 1 (1) | 21 (26) | 59 (72) | 4.7 | 0 (0) | 0 (0) | 4 (4) | 29 (30) | 63 (66) | 4.6 | .35 | ||
3. The doctor understood my presentation well. | 0 (0) | 0 (0) | 6 (7) | 20 (24) | 56 (68) | 4.6 | 0 (0) | 0 (0) | 6 (6) | 29 (30) | 61 (64) | 4.6 | .58 | ||
4. The doctor clearly explained evaluation and X-ray results to me. | 0 (0) | 1 (1) | 3 (4) | 16 (20) | 62 (76) | 4.7 | 0 (0) | 2 (2) | 8 (8) | 25 (26) | 61 (64) | 4.5 | .07 | ||
5. I could hear the doctor’s voice clearly. | 0 (0) | 0 (0) | 2 (2) | 23 (28) | 57 (70) | 4.7 | 0 (0) | 1 (1) | 5 (5) | 24 (25) | 66 (69) | 4.6 | .78 | ||
6. I had enough time to ask questions. | 1 (1) | 0 (0) | 3 (4) | 21 (26) | 57 (70) | 4.6 | 0 (0) | 2 (2) | 4 (4) | 28 (29) | 62 (65) | 4.6 | .48 | ||
7. I felt relaxed when I talked to the doctor. | 1 (1) | 0 (0) | 3 (4) | 19 (23) | 59 (72) | 4.6 | 0 (0) | 1 (1) | 7 (7) | 21 (22) | 67 (70) | 4.6 | .67 | ||
8. During the visit, I was not scared or stressed. | 1 (1) | 0 (0) | 3 (4) | 18 (22) | 60 (73) | 4.7 | 0 (0) | 3 (3) | 4 (4) | 26 (27) | 63 (66) | 4.6 | .27 | ||
9. I did not feel discriminated during the visit. | 1 (1) | 0 (0) | 2 92) | 17 (21) | 62 (76) | 4.7 | 0 (0) | 0 (0) | 4 (4) | 25 (26) | 67 (70) | 4.7 | .40 | ||
10. My privacy was well-protected. | 0 (0) | 1 (1) | 6 (7) | 19 (23) | 56 (68) | 4.6 | 0 (0) | 0 (0) | 7 (7) | 27 (28) | 62 (65) | 4.6 | .69 | ||
11. I think video interviews are acceptable. | 0 (0) | 0 (0) | 2 (2) | 22 (27) | 58 (71) | 4.7 | N/Ae | N/A | N/A | N/A | N/A | N/A | N/A | ||
12. I felt safe during the video interview. | 1 (1) | 0 (0) | 4 (5) | 15 (18) | 62 (76) | 4.7 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | ||
13. I am satisfied with the video interview. | 1 (1) | 0 (0) | 2 (2) | 18 (22) | 61 (74) | 4.7 | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
aA total of 11 non-respondents in the telemedicine group were excluded.
bA total of 9 non-respondents in the conventional group were excluded.
cAnalyzed using the Mann-Whitney U test.
d5-point Likert scale: 1. Strongly disagree. 2. Disagree. 3. Neutral. 4. Agree. 5. Strongly agree.
eNot applicable.
This study shows that the double triage and telemedicine protocol in the ED could reduce physicians’ time of exposure to patients who pose a risk of COVID-19 transmission without compromising patient satisfaction. The time of direct exposure to individual patients in the telemedicine group could be 39% to 64% of that in the conventional group. During the COVID-19 pandemic, our protocol could effectively protect our health care workers from contracting infections in the ED. Moreover, wearing PPE has been shown to constrict mobility and vision and cause heat stress and dehydration, especially in hot weather [
Our study has some limitations that must be addressed. First, it was a retrospective study using prospectively collected data. Confounding factors during this period, including policy changes, patient characteristics, medical resources, and laboratory examination, may have affected the study results. However, the patients in both the telemedicine group and the conventional group were relatively comparable. The policy in Taiwan and the criteria of reporting remained roughly unchanged, leading to small confounding effects of time and other policy factors. Second, our patients were relatively young, and telecommunication use was quite common among them; this explains their high familiarity with and acceptance of video interviews. Further studies should therefore investigate the feasibility and benefits of telemedicine among older adults. However, in our COVID-19 emergency clinic, a nurse was assigned to assist patients in receiving video calls if needed, and the patients’ families were allowed to accompany them in the clinic and could also help them use the TIS. These mechanisms facilitated the efficient functioning of the system. Third, in our study, 203 patients were excluded due to high TTAS levels. The feasibility of telemedicine for these patients was not investigated. Because these patients are usually in critical condition, face-to-face emergent management may be necessary in clinical scenarios. The possible application of telemedicine with critical patients should be further developed and examined. Fourth, the study was conducted at a single ED in Taiwan. Therefore, the generalizability of the novel model has not been confirmed. Furthermore, the cultural differences between Taiwan and other countries should be considered to ascertain the effectiveness of the proposed model.
The double triage method in our protocol facilitated the use of a TIS. The epidemic of an emerging infectious disease may cause a surge of patients in EDs due to clinical symptoms or fear of the disease. This may overwhelm the health care capacity of overcrowded EDs and aggravate the risk of cross infection in hospitals [
Telemedicine has long been used to provide medical care in remote areas and has proved to be beneficial in infection control and management. The published literature demonstrates that telemedicine can increase access to care, with high patient satisfaction, improved outcomes, and reduced costs [
The use of video interviews in our TIS had certain advantages over telephonic or conventional methods. Through face-to-face communication, we can directly confirm the identity of patients in routine practice and examine their general appearance and respiratory status. Moreover, the telemedicine system has a share function that can help physicians to simultaneously send high-quality images, laboratory data, and health information to their patients. Notably, our study results showed that the telemedicine group had a more favorable impression of the quality of images and interpretation of laboratory studies than the conventional group, although no statistical significance was observed.
Certain concerns exist about the feasibility and acceptance of telemedicine, especially in the context of the pandemic [
The implementation of a double triage and telemedicine protocol during the COVID-19 pandemic has high potential to improve infection control. Our study preliminarily validated a promising model in the ED to minimize physicians’ direct contact with non-critical suspected COVID-19 patients during evaluation. During the pandemic, this model could help protect critical medical personnel in the health care system from unnecessary exposure and further prevent overwhelming of the health care system.
Photographs of the physician's site (A) and the patient’s site (B) in the COVID-19 emergency clinic.
US Centers for Disease Control and Prevention
coronavirus disease
emergency department
Middle Eastern respiratory syndrome
National Taiwan University Hospital
personal protective equipment
reverse transcription–polymerase chain reaction
severe acute respiratory syndrome
severe acute respiratory syndrome coronavirus 2
telemedicine interview system
travel, occupation, contact, and cluster
Taiwan Triage and Acuity Scale
CHL, WPT, JLW, JT, and MTC conceived and designed the studies. CHL, HNO, HYL, YYC, CHW, and JWC contributed to the acquisition of the data. CHL and WPT contributed to the analysis of the data. The manuscript was drafted by CHL, WPT, CCC, CHH, and SCC. CCC, CHH, and SCC supervised the trial and data collection.
None declared.