Practise examples

COVID-19 risk stratification in the emergency department

Emergency departments are facing enormous challenges during the coronavirus pandemic. A new triage model at the Göttingen-Weende Hospital ensures early detection of COVID-19 as well as patient isolation. This efficient risk stratification also succeeds in protecting vulnerable groups in all areas of the hospital.

How can an emergency department (ED) with around 30,000 emergencies per year operate efficiently in the context of SARS-CoV-2 while ensuring protection against nosocomial spread of the pathogen? Marc Wieckenberg, Head Physician of the ED at the Evangelisches Krankenhaus Göttingen-Weende, and his colleagues answered this question with a model for risk stratification of suspected SARS-CoV-2 and COVID-19 cases [1]. Based on the epidemiological criteria of the Robert Koch Institute and internal case definitions, the emergency physicians defined five risk categories.

COVID-19 risk categories I-V:
RK I = Confirmed SARS-CoV-2 infection
RK II= COVID-19 Reasonable Suspicion
RK III=COVID-19 Differential diagnosis
RK IV= COVID-19 19 Low probability
RK V = COVID-19 No suspicion

Aim: Comprehensive protection against infection

A standardized treatment procedure for emergency diagnostics and therapy has been established for all emergency patients on the basis of the system of risk categories I-IV. This procedure is used to strictly separate COVID-19/non-COVID-19 emergencies, thereby protecting staff and patients against nosocomial infection. The focus is on particularly vulnerable groups, such as patients with risk factors including advanced age, immunodeficiency, lung, heart and kidney diseases and malignancies.

In order to establish risk stratification, considerable structural changes within the hospital building were necessary, for example to enable CT and conventional X-ray diagnostics for accident victims with an increased risk of COVID-19. The changes were implemented by measures such as

  • Installing a walk-through tent to protect waiting patients from the weather
  • Expanding the available space by means of movable partitions
  • Integrating the trauma room CT into the isolation area
  • Separating the isolation ED from the routine ED by means of a rolling grille and airlock system
  • Relocating the main entrance and closure of all side entrances
  • A Plexiglas-protected space for patient interviews and administration

Standardized procedure for all emergency patients

Risk stratification becomes the central means of controlling patient flows in the ED by linking the respective risk category to criteria such as

  • Symptoms and/or occupational group
  • Specific hygiene protection measures
  • Specific treatment room within the ED
  • Specifying the room used for further inpatient care

Treatment Procedure in the ED

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Treatment Procedure in the Emergency Department

1. Initial coronavirus screening by the doctor in charge and the ED nurse according to the dual-control principle.
2. Determining the COVID-19 risk status. 
3. Triage using the Manchester Triage System (MTS) to determine the urgency of treatment.
4. Allocation of the primary, appropriately labeled treatment and isolation site in the ED.
5. Determining hygiene protection measures according to risk category.
6. Emergency diagnostics (vital signs, laboratory diagnostics, nasopharyngeal swab/gargle test, thoracic ultrasound, low-dose CT in cases of reasonable suspicion).
7. Re-evaluation of the COVID-19 risk status if the patient is to be hospitalized.
8. Selection of the appropriate ward according to risk category:

RC II and RC III = suspected COVID-19 ward NC/IMC/ICU
RC IV and RC V = Pre-isolation NC/IMC/ICU
(Barrier measures; no further functional diagnostics until test result)


Wieckenberg M, Meier V, Pfeiffer S, Blaschke S. Risikostratifizierung von Notfällen während der COVID-19-Pandemie in der Zentralen Notaufnahme. Med Klin Intensivmed Notfmed, Springer, Eingegangen: 4. Juni 2020. Überarbeitet: 21. August 2020. Angenommen: 12. September 2020.

More articles:
„Hygiene in context with Corona“
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