Application and effects of fever screening system in the prevention of nosocomial infection in the only designated hospital of coronavirus disease 2019 (COVID-19) in Shenzhen, China

Ting Huang1, Yinsheng Guo2 , Shaxi Li1, Yanqun Zheng1, Lin Lei1, Xianhu Zeng1, Qiao Zhong3, Yingxia Liu1 and Lei Liu1 1Department of Healthcare-Associated Infection Management, National Clinical Research Center for Infectious Diseases, Third People’s Hospital of Shenzhen (Second Affiliated Hospital of Southern University of Science and Technology), Shenzhen, Guangdong, China, 2Environment and Health Department, Shenzhen Center for Disease Control and Prevention, Shenzhen, Guangdong, China and 3Department of Healthcare-Associated Infection Management, Shenzhen Maternity and Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China

great deal of work in the prevention of virus transmission, cross infection, and medical staff infection. 8 They initiated the first fever screening system, which has played an important role in the prevention and control of hospital infection.

Three levels of triage for fever patients
To avoid the cross infection of patients in outpatient treatment, the hospital strictly controls entry to and exit from the outpatient area. The outpatient hall and emergency hall each have only 1 entrance and 1 exit. Upon arrival, all patients need to go through "3 passes." The first pass is the pre-examination and triage stage where doctors and nurses take temperature measurements and do a triage evaluation. The epidemiological history and clinical symptoms of the patients are carefully collected by the triage personnel. Each fever patient is issued a surgical mask and provides registration details traceability. According to the specific content of the questionnaire, an Healthy-QR color code is set as red, yellow, or green. Patients assigned a red code are escorted to the fever clinic by special staff on a designated route. The yellow code is used to alert the follow-up clinic after the discharge of a COVID-19 patient. A green code provides the patient entry to the outpatient hall. The second pass is a specialized triage pass. The patient first presents the Healthy-QR color code assigned in the first pass. The triage nurse takes the patient's temperature again and acquires an oral epidemiological history. In the third triage pass, the patient enters a consulting room, where a doctor signs off on the patient's written epidemiological history and the patient's medical history. These two signed notices are then filed. In the second and third triage passes, the patients identified with fever at the pre-examination are delivered to the fever clinic along a designated route by assigned staff from the pre-examination triage. The areas that the patients pass through are disinfected immediately.
The flowchart for pre-examination and the 3-stage triage system are shown in Fig 2. From January 11 to March 1, a total of 421 people went to the fever clinic under the oversight of the outpatient pre-examination triage office. Among them, 12 patients were confirmed to have COVID-19. The strict 3-level triage prevents COVID-19 patients from infecting other patients or medical staff in the public area of the clinic.

District management of fever clinics
The fever clinic is located in an independent area far from the clinic hall. The patient hallway and the medical staff hallway are independent and do not intersect. The fever clinic comprises consulting rooms, a waiting area, a charge office, a pharmacy, a specimen collection office, a x-ray examination area, and resuscitation rooms. To our knowledge, this is the first time a fever clinic has been divided into different areas. The 2 fever clinics are relatively independent and do not overlap. Patients are screened and assigned a Healthy-QR color code (Fig. 3). The red Healthy-QR code indicates that the patient has an epidemiological history and that the patient should go to fever clinic 1 for treatment. The green Healthy-QR code indicates that the patient has no epidemiological history, and the patient should go to fever clinic 2 for treatment.
As shown in Table 1, the fever clinics received 2,140 visits from January 24 to March 1. Among them, 1,408 patients were admitted to fever clinic 1, and all patients were given a nucleic acid test (NAT) for SARS-Cov-2. In addition, 56 patients were NAT positive, and the NAT-positive rate for SARS-CoV-2 was 3.98%.
Meanwhile, 732 patients were admitted to fever clinic 2, and all patients were tested for the NAT. Among them, 2 cases were NAT positive, and the NAT-positive rate was 0.27%. The difference in NAT-positive rates between the 2 fever clinics was statistically significant (χ 2 = 25.059; P < .001). Thus, we conclude that this method effectively prevents cross infection of patients in the fever clinic.
Our hospital has made great contributions to both the treatment of patients and the prevention of the spread of this epidemic. By March 1, a total of 418 cases of COVID-19 had been admitted to this hospital, and 163 cases had been discharged. Meanwhile, none of the 1,264 medical staff had been infected. Moreover, no cross infection had occurred among the 1, 870 other patients hospitalized during the same period.
Reviewing the cross infections and medical staff infections in other hospitals, we offer our hypotheses for several main reasons for cross infection in hospitals. First, the patients did not undergo strictly screening and triage before treatment. Second, the division of treatment zones between suspected patients and ordinary patients were not clear. Third, suspected patients were neglected and personal protective equipment of medical staff was inadequate in the early stage of the epidemic.
We offer our experience regarding the fever screening system at our institution for the benefit of other hospitals involved in the treatment of patients infected with COVID-19. We believe that comprehensive victory over the new coronavirus pneumonia epidemic is not far away.