Journal of Infection and Public Health 14 (2021) 1212–1217

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Journal of Infection and Public Health

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Original Article

Evaluation of a combination protocol of CT-first triage and active

telemedicine methods by a selected team tackling COVID-19: An
experimental research study
Shigeta Miyake a,b , Takuma Higurashi a,c,∗ , Hideaki Kato a,d , Yutaro Yamaoka e,f ,
Takaomi Kessoku c,g , Shingo Kato c,h , Fumihiro Ogawa a,i , Yasufumi Oi a,i ,
Atsushi Nakajima a,c , Tetsuya Yamamoto a,b , Ichiro Takeuchi a,i , Akihide Ryo e ,
Shin Maeda a,j
a
Team COVID-19, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
b
Department of Neurosurgery, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
c
Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004,
Japan
d
Infection Prevention and Control Department, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Japan
e
Department of Microbiology, Yokohama City University School of Medicine, Kanagawa 236-0004, Japan
f
Life Science Laboratory, Technology and Development Division, Kanto Chemical Co., Inc., Kanagawa 259-1146, Japan
g
Palliative Care Medicine Department, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
h
Department of Clinical Cancer Genomics, Yokohama City University, 3-9, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
i
Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan
j
Department of Gastroenterology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama 2360004, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Background: Many health care workers around the world tackled with COVID-19, however sadly, the
Received 27 January 2021 infection of many medical care workers were reported. To reduce the risk of infection, we launched
Received in revised form 27 July 2021 selected team (Team COVID) of non-specialists and brought in active telemedicine method and computed
Accepted 15 August 2021
tomography (CT)-first protocol. We describe our actual practice and the health status of medical doctors
dealing with COVID-19 patients.
Keywords:
Methods: Between April 17, 2020 and May 24, 2020, 10 doctors worked with COVID-19 patients as part
COVID-19
of Team COVID. The Team COVID doctors used a CT-first triage protocol for outpatients and telemedicine
CT-first triage
Health of medical stuff
for inpatients and outpatients. We evaluated paired serum-specific antibodies for SARS-CoV-2 at the
Medical care team initial and end of the study duration and PCR results for SARS-CoV-2 at the end of the study duration.
Telemedicine Furthermore, 36-item short-form of the Medical Outcome Study Questionnaire (SF-36) at the beginning
and end of the study period were evaluated.
Results: Ten doctors worked as Team COVID: seven internal medicine doctors and three surgeons. During
the study period, Team COVID treated 165 individuals in the outpatient clinic and isolated hospital-
ized patients for 315 person-days. There were no positive results of serum-specific antibody testing and
PCR testing for SARS-CoV-2 in Team COVID doctors. Furthermore, the SF-36 showed no deterioration in
physical and mental QOL status. No in-hospital infection occurred during the study period.
Conclusions: The Team COVID fulfilled the treatment using the active telemedicine and CT-first triage
protocol without in hospital infection and excess stress. The combination strategy seems acceptable for
both the protection and stress relief among the medical staff.
© 2021 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for
Health Sciences. This is an open access article under the CC BY-NC-ND license ([Link]
org/licenses/by-nc-nd/4.0/).

Abbreviations: CO-RADS, coronavirus disease 2019 reporting and data system; COVID-19, coronavirus disease 2019; CT, computed tomography; ELISA, enzyme linked
immunosorbent assay; MCS, Mental Component Summary; PCR, polymerase chain reaction; PCS, Physical Component Summary; PPE, personal protective equipment; QOL,
quality of life; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; SF-36, 36-item short form of the medical outcome study questionnaire.
∗ Corresponding author at: Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa, Yokohama
2360004, Japan.
E-mail address: takuma h@[Link] (T. Higurashi).

[Link]
1876-0341/© 2021 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC
BY-NC-ND license ([Link]
S. Miyake et al. Journal of Infection and Public Health 14 (2021) 1212–1217

Introduction ing COVID-19 in 24-h rotations. In our hospital, a protocol that

used computed tomography (CT) as the first-line examination, i.e.,
Coronavirus disease 2019 (COVID-19), which is caused by “CT-first triage protocol [16]” was adopted for the management of
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has suspected COVID-19 patients. Additionally, we adopted the active
affected more than 7.8 million individuals and has caused more telemedicine method for both outpatients and inpatients.
than 0.43 million deaths to date [1]. The second and third waves
of COVID-19 infection are expected. The pandemic of COVID-19 is
one of the greatest human challenges facing healthcare systems Ethical approval and study registration
on a global scale in this century [2,3]. In Italy, 20% of all infec-
tious persons were medical care workers [4]. To prevent outbreaks The Institutional Review Board at Yokohama City University
of COVID-19 in hospitals, the adequate use of disposable personal Hospital approved this study (approval number B200400091).
protective equipment (PPE) is recommended [5]. Additionally, it is Written consent for participation in this prospective study was
advisable to separate services for patients suspected of COVID-19 obtained from all the participants. This study has been registered
[6,7]. in the University hospital Medical Information Network (UMIN)
To maintain the healthcare capacity and quality in emergency Clinical Trials Registry as UMIN000040129.
situations, health management of healthcare workers is one of
the most important requirements [8]. In the COVID-19 pandemic,
because of the absence of a vaccine, rapid testing, and standard Participants
treatment, healthcare workers have been subjected to immense
physical and psychological stress [9]. Especially, in emergency sit- Team COVID consisted of 10 doctors (mainly selected from the
uations such as the COVID-19 pandemic, an urgent response team Department of Internal Medicine and Surgery), all of whom were
comprising different specialties often tackles triage and treatment included this study.
[10,11]. In general, these urgent response teams face more stress We analyzed the following baseline characteristics: age, sex,
than ordinary medical workers because they deal with unfamiliar specialties, history of overseas travel from January 2020 to April
diseases and are at risk of infection themselves. In order to practice 2020, contact history with COVID-19 patient, and serum-specific
adequate medical care, standard triage and treatment protocols are level of SARS-CoV-2 antibody.
essential. At the same time, in order to sustain the teams, provision
of medication and appropriate protection measures for healthcare
workers is crucial [10]. Active telemedicine method
A reasonable and reliable protocol for reducing contact with
COVID-19 patients is important for both patients and health- In the outpatient clinic, suspected COVID-19 patients were
care workers. Therefore, several triage protocols and telemedicine guided to a temporary tent (Fig. 1A). In the temporary tent, there
methods for triage of COVID-19 patients have been reported were intercoms (VL-SE25K, Panasonic Corporation, Osaka, Japan)
[12–14]. The triage using present history and radiological features connected to the emergency room (Fig. 1B). Nurses and doctors took
has been found to shorten the diagnostic duration and help narrow the medical interview and observed the patient situation through
down the suspected patients [15]. Additionally, telemedicine using the intercom. If a patient visited our hospital by his/her own car, the
current technology promotes contactless medical care [16]. There- nurses and doctors communicated with the patient using a mobile
fore, we incorporated the combination protocol of triaging method phone, with the patient seated in the car.
and telemedicine in our hospital. When treating inpatients, doctors took rounds using room
Here, we describe our actual practice including selected team cameras (DH-IPC-HDBW1220EN-S-0280B, Dahua Technology Co.,
formation and the combination protocol. Additionally, the health Ltd, Hangzhou, China) and nurse call phones (PLAIMH NICSS,
status of medical doctors dealing with COVID-19 patients was Carecom Co., Ltd, Tokyo, Japan) (Fig. 1C and D). Only when the
assessed. In this study, we aimed to assess the sustainability of patents required direct medical examination or the patient’s status
healthcare systems in emergency situations by examining our com- changed, the doctors entered the isolation room (Fig. 1E) donning
bination protocol of triaging method and telemedicine in terms of PPE.
infectivity and mental health.

CT-first triage protocol

Material and methods
We previously reported the efficacy of the CT-first protocol for
Study design and setting triage [15]. In brief, patients complaining of COVID-19 symptoms
were instructed to visit the fever outpatient clinic of the emergency
This study is a single-center experimental study that evaluated room. These patients were isolated from other patients and treated
medical doctors at Yokohama City University Hospital, prospec- as suspected COVID-19 patients. The nurse of a fever outpatient
tively registered between April 17, 2020 and May 15, 2020. clinic is equipped with PPE and briefly checks the patients’ vital
Yokohama is the second largest city in Japan after Tokyo; COVID- signs and history. Chest CT was performed. Patients suspected of
19 has affected 17.502 individuals and caused 890 deaths in Japan COVID-19 were separated from other patients on traffic lines and
as of June 15, 2020 [17]. In Yokohama City University Hospital, a elevators to the CT room. Every CT feature was interpreted imme-
tertiary-level hospital in Yokohama, we treated COVID-19 patients, diately by specialized radiologists and COVID-19 team doctors; the
who were affected by the outbreak in the “Diamond Princess” cruise patients were classified into five categories according to the COVID-
ship in Yokohama Bay from February 2020 [18–20]. A selected 19 Reporting and Data System (CO-RADS) [20]. According to the
team (Team COVID) was launched to treat patients with moderate- CO-RADS score and patient history, patients were separated into
to-severe COVID-19 symptoms and identify suspected COVID-19 a “COVID-19 suspected” group or a “COVID-19 less likely” group.
patients to prevent the spread of infection to in-hospital patients In the COVID-19-suspected group, the isolation and PPE support
and medical staff. The Team COVID doctors were engaged in the continued until the polymerase chain reaction (PCR) test showed
outpatient clinic and treated in-hospital patients suspected of hav- negative results.

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S. Miyake et al. Journal of Infection and Public Health 14 (2021) 1212–1217

Table 1
Participants characteristics.

Team COVID

Number 10
Age 33.8 ± 6.5
Sex (male, female) 9, 1
Internal medicine 7
Specialty Surgery 3
Infection 0
History of overseas 0
Rich contact with COVID-19 0

Abbreviations: COVID-19: coronavirus disease 2019.

extraction was used for the reaction of Real Time quantitative PCR
(RT-qPCR). The RT-qPCR Reaction Mix was prepared with TaqMan
Fast Virus 1-Step Master Mix (Thermo Fisher Scientific, City) and
Primer/Probe N2 (2019-nCoV) (TAKARA, City, japan) according to
the manufacture’s protocol. The sequences of the primers were
shown in the supplementary Table 1. Denature and anneal/extend
steps were repeated 45 cycles. Absolutely quantified artificial syn-
thetic template RNA was used as positive control, whereas the well
that contain no template RNA was used as negative control. Accord-
ing to the Manual [23], the assay was considered valid when the
assay meets the following criteria; the 50 copies/well of template
RNA was successfully detected before 40 cycles. (b) The nonspe-
cific amplification was not detected in the well with no template
RNA until 45 cycles. The sample that was detected the amplifica-
tion of COVID-19 genomic RNA before 40 cycles was determined as
positive for COVID-19 in this study.
We previously reported the methodology of serological testing
[24,25]. In brief, enzyme linked immunosorbent assay (ELISA) was
performed to detect and quantify anti–SARS-CoV-2 antibodies in
plasma. We used n coronavirus-N-terminally truncated nucleocap-
sid protein as the antigen. In serological test, cut-off of COVID-19
Fig. 1. Active telemedicine method for COVID-19 suspected patients. antibody positive was over 0.45.
The applications for the active telemedicine method were shown. (A) The temporary
tent for the feverish outpatients. (B) The intercom in the temporary tent. The inter-
com connected outpatient and medical staff without contact. (C) The room camera
Statistical analysis
of isolating inpatient. (D) The medical question through the nurse call phone. (E)
The isolating inpatient area.
The results are presented as means for the quantitative
data and as frequencies (percentage) for categorical data. The
Calculation Mann–Whitney U test was used for continuous data. A p value <0.05
was considered statistically significant. All statistical analyses were
Outcome performed using JMP® 15 (SAS Institute Inc., Cary, NC, USA).

We evaluated the number of inpatients and outpatients treated

by Team COVID. We also evaluated paired serum-specific antibod- Results
ies for SARS-CoV-2 at the initial and end of the study duration and
PCR results for SARS-CoV-2 at the end of the study duration. Fur- Participant characteristics
thermore, we evaluated the responses to the 36-item short-form
of the Medical Outcome Study Questionnaire (SF-36) at the begin- Between April 17, 2020 and May 15, 2020, 10 doctors worked
ning and end of the study period. SF-36 can evaluate the physical with COVID-19 patients as part of Team COVID: seven internal
and mental quality of life (QOL) as 2 Physical Component Summary medicine doctors and three surgeons. There was no infection spe-
(PCS) and 2 Mental Component Summary (MCS) [21,22]. cialist; however, the infection specialist supervised the activities of
Team COVID. The mean age was 33.8 ± 6.5 years, and nine doctors
Detection of COVID-19 genomic RNA and serological test for were male in Team COVID. There was no history of travel abroad
COVID-19 antibody before the study period (from January 2020 to April 2020) (Table 1).

The detection of COVID-19 genomic RNA was performed accord-

ing to the Manual for the Detection of Pathogen 2019-nCoV Ver.2.6 Number of outpatients and inpatients treated by the Team COVID
[23] provided by National institute of infectious disease in Japan.
Nasal swab samples were obtained using Flocked Nasopharyngeal During the study period, 165 individuals visited the outpatient
Swab (COPAN, City). The RNA extraction was performed from 140 clinic. Thirty-eight patients suspected of COVID-19 were hospi-
␮l sample using QIAamp Viral RNA Mini Kit (QIAGEN, City) accord- talized, and a total of 12 patients were finally diagnosed with
ing to the manufacture’s protocol. The final elution was performed COVID-19 (Fig. 2). Team COVID members treated isolated hospi-
with 60 ␮l of elution buffer in the kit, and five ␮l of the RNA talized patients for 315 person-days.

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S. Miyake et al. Journal of Infection and Public Health 14 (2021) 1212–1217

Fig. 2. Activities of Team COVID.

The overview of activities of Team COVID according to combination protocol of CT-first triage protocol and telemedicine method. The yellow area means isolating duration,
requiring personal protective equipment. During the isolating duration, active telemedicine was applied for coronavirus disease 2019 (COVID-19) suspected or confirmed
patients. The CVID-19 less likely group was treated normal equipment and finally diagnosed with further examinations. The needs for hospitalization of COVID-19 suspected
group were judged personally according to their severity. The patients negative for polymerase chain reaction (PCR) for severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) were treated normal equipment and finally diagnosed with further examinations.

Table 2 in Team COVID. Furthermore, Team COVID members showed stable

Outcomes of participants.
QOL score evaluated with the SF-36 questionnaire. We previously
Initial of study End of study reported the efficacy of the CT-first triage protocol for patients sus-
period period pected of COVID-19 [15]. Therefore, our combination protocol of the
Serological test for COVID-19 0.22 ± 0.16 (n = 0.21 ± 0.15 (n = CT-first triage and active telemedicine seems permissible for both
antibody (absorbance, 0, 0.0%) 0, 0.0%) management of patients and protection of healthcare workers.
positive: n, %) In Yokohama City University, the selected team called Team
PCR test (positive: n) positive: none
COVID was launched to tackle COVID-19. These emergency
SF-36 2PCS* 53.9 ± 3.6 54.2 ± 3.8 p = 0.94
SF-36 2MCS* 56.8 ± 7.5 56.5 ± 8.1 p = 0.91 response teams consisted of non-specialist and worked in emer-
gency situations [10]. Recently, when the MARS and SARS outbreaks
In serological test, cut off of COVID-19 antibody positive is over 0.45.
Abbreviations: COVID-19: Coronavirus disease 2019, PCR: Polymerase chain reac- spread in Asia, several emergency teams were launched in the
tion, SF-36: 36-item short form of the medical outcome study questionnaire, MCS: high-risk area [26,27]. These teams are useful for minimizing the
Mental Component Summary, PCS: Physical Component Summary. influence on general healthcare capacity and increasing the number
of staff trained in unfamiliar diseases. In our hospital, Team COVID
The results of serological antibody for SARS-CoV-2 and PCR test, doctors covered the COVID-19 suspected or confirmed patients
physical and mental status in the Team COVID doctors fully, therefore, the other doctors were able to maintain the qual-
ity and capacity of the usual medication. Furthermore, because the
Serum-specific antibody testing showed no positive results for Team COVID doctors were limited number, the treatment protocol
the doctors during the study period both in team COVID. The was easy to establish and update for all members. In our experi-
absorbance values of the ELISA of Team COVID were 0.22 ± 0.16 ence, Team COVID members were not infected during the study
at initial and 0.21 ± 0.15 at the end of study period. PCR testing for period. The team formation may have advantage to maintain the
SARS-CoV-2 at the end of the study period did not show any pos- appropriate infection protection.
itive results. It means there no COVID-19 infection during study However, high stress is a matter of concern for these team mem-
period. Furthermore, the SF-36 showed no deterioration in physi- bers [28,29]. There were several evidences of health care workers
cal and mental QOL status (Table 2). The 2PCS score of Team COVID tackling COVID-19 to face the high risk of infection and receive
were 53.9 ± 3.6 at initial and 54.2 ± 3.8 at the end of study period strong stress leading poor QOL [4,9]. In this study, we confirmed
(p = 0.94). The 2MCS score of Team COVID were 56.8 ± 7.5 at initial that the physical and mental QOL score did not drop in Team COVID.
and 56.5 ± 8.1 at the end of study period (p = 0.91). There were no We emphasize that the Team COVID carried out appropriate triage,
statistically significant differences between initial and end of QOL examination, and treatment following the combination protocol
score evaluated with SF36 both 2PCS and 2MCS within the Team of CT-first triage and active telemedicine without excessive stress.
COVID. With the use of the combination protocol of CT-first triage Therefore, the appropriate protocol maintained the QOL of health
and active telemedicine, no in-hospital infection occurred during care workers tackling COVID-19, and this combination protocol
the study period. may potentially contribute to overcome the demerits of emergency
team formations.
Discussion Telemedicine is attracting attention for overcoming infectious
diseases [16]. Several new technologies have been reported, such
In this study, we demonstrated Team COVID activities and our as remote diagnostic technology using artificial intelligence and
actual practice of the combination protocol using CT-first triage telemedicine, for triage systems [30]. Robotic technology for
and active telemedicine for COVID-19 patients. In our experience, remote medical systems is also reported to help medical systems
with the combination protocol, the Team COVID carried out ade- tackle COVID-19 [31]. These technologies are promising, as they
quate treatments and there were no cases of COVID-19 infections have the potential for improving the safety of the medical staff.

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