Triage Nurse Instructions

Triage Nurse Instructions


Screen all patients for any of the following symptoms within the last 7 days:

COVID-19 Core Respiratory Symptoms (new or worse):

  • Cough
  • Fever/chills/rigors:
    • Adults >37.8°C (reported or documented)
    • Pediatrics ≥38.0°C (reported or documented)
  • Shortness of breath, increased O2 requirements, difficulty breathing
  • Sore throat/painful swallowing
  • Runny nose/nasal congestion

COVID-19 Gastrointestinal (GI) Symptoms (new or worse):

  • Vomiting
  • Diarrhea

Must have had 2 or more episodes of vomiting and/or diarrhea

Seasonal ILI Symptoms (see below), plus one of the following:

  • Immunocompromised, critical respiratory failure, or outbreak investigation
    • Adults: New or changed cough AND fever (38.0°C or higher) AND any of the following: sore throat, joint pain, muscle ache, extreme exhaustion/weakness
    • Pediatrics: cough OR sneezing OR runny nose

Screen all patients for ANY of the following Risk Factors

  • COVID-19 test; positive COVID-19 within the last 14 days or currently pending
  • Had close contact* with a confirmed or probable case of COVID-19 within 14 days before illness onset
  • Had close contact* with a person with acute respiratory illness who has travelled anywhere outside of Canada in the 14 days before their illness
  • Travelled anywhere outside of Canada within the last 14 days
  • Had laboratory exposure to biological material known to contain COVID-19 virus within the last 14 days
  • Associated with any healthcare unit/facility, congregate living, or other (e.g. workplace or social gathering) COVID-19 outbreak/cluster
  • Direction has been given for the patient to remain on Contact & Droplet Precaution

A close contact is someone who:

  • Provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact with the person without consistent and appropriate use of personal protective equipment (PPE)


  • • Lived with or otherwise had close prolonged contact which may be cumulative, i.e., multiple interactions for a total of 15 min or more and within two metres with a case without consistent and appropriate use of PPE and not isolating


  • Had direct contact with infectious body fluids of a someone who has tested positive for COVID-19 (e.g., shared cigarettes, glasses/bottles, eating utensils) or was coughed or sneezed on while not wearing recommended PPE