key: cord-0758272-jta208r9
authors: Pivetta, Emanuele; Lupia, Enrico; Cerini, Gabriele; Prota, Alessio; Nazerian, Peiman
title: Mild COVID-19 patients can be safely discharged from emergency department: prospective bicentric pilot study
date: 2021-04-27
journal: Eur J Emerg Med
DOI: 10.1097/mej.0000000000000782
sha: 083db5826586423fe6bc6a1f48f1f2ff64a16fc6
doc_id: 758272
cord_uid: jta208r9

nan

Since the end of 2019, a global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic spread in most countries all over the world. In Italy as in many other countries, admission to acute hospitals was reserved to moderate-severe cases while patients with mild coronavirus 2019 (COVID-19) were managed in home isolation. During the last months, several studies have been published regarding prognostication and factors associated with hospital admission of patients with COVID-19 [1] [2] [3] [4] [5] [6] . Nevertheless, no prospective studies specifically evaluate the safety of discharge patients from emergency department (ED) using simple criteria to identify mild COVID-19. The aim of our study was to evaluate the rate of readmission or death within 30 days from ED index visit in patients with mild COVID-19 discharged from ED.

This was an observational bicentric prospective study approved by the ethical committees of involved hospitals. Informed consent was obtained from study patients. Consecutive patients discharged from the EDs of two Italian university hospitals were enrolled from 1 to 30 April 2020. Patients were included in the study if: age ≥18 years, diagnosis of COVID-19 based on positive rRT-PCR respiratory specimen performed in ED, discharged from ED and first presentation in ED during the study period. Exclusion criteria were: patients refused hospitalization, patients lost at follow-up and the patient declined to participate in the study. All patients included in the study were evaluated by a staff physician or a resident working in ED. All patients underwent history taking, physical examination, bedside diagnostic imaging test (lung ultrasonography or anteroposterior (AP) chest X-ray). The criteria used to define mild COVID-19 patients candidate for ED discharge based on hospitals' protocol were: oxygen saturation >94% or >90% in patients with chronic obstructive pulmonary diseases, respiratory rate ≤20/min, no need for oxygen therapy or ventilation, <3 points desaturation to 20-m walking test (if possible to perform), normal bedside diagnostic imaging test (lung ultrasound performed by the treating physician after clinical evaluation or antero-posterior chest X-ray performed by a radiology technician at the bedside). In patients with doubtful or only mild alteration to bedside diagnostic imaging tests, the discharge could be considered by treating physician case by case. Blood gas analysis, ECG, COVID-19 panel of blood samples, and computed tomography were performed based on physician evaluation. The decision to discharge patient was established by the treating physician independently to study participation. After 30 days from ED index visit, patients underwent a structured telephone interview performed by a physician, evaluating ED re-attendance, admissions to the general hospital ward, to ICU and death. Furthermore, local hospital database search for additional ED visits and hospital admissions were performed. The outcomes of the study were death and hospital admission within 30 days after ED discharge.

During the study period, 298 patients had a final diagnosis of COVID-19, of whom 111 (37%) were discharged and included in the study. No patients refused to participate in the study or were lost at follow-up. Table 1 reports the general characteristics of the 111 enrolled patients. Clinical criteria for discharge were present in all patients except in 10 (9%) cases with a respiratory rate >20 breaths per minute. Lung ultrasound was performed in 97 (87%) showing normal A-line pattern in 44 (40%), focal interstitial syndrome in 38 (34%), diffuse interstitial syndrome in 13 (11%) and consolidation in 2 (2%) patients. Chest X-ray was performed in 56 (51%) patients, it was normal in 46 (41%) patients, in 4 (4%) patients showed monolateral and in 13 (12%) bilateral consolidations. No patients had pleural effusion at lung ultrasound or chest X-ray. Twelve (11%) patients re-attended ED during the follow-up period however only 1 (1%) was admitted to the general ward for 7 days because of worsening after 9 days from the first ED visit. The admitted patient was a 58-years-old healthy healthcare worker presenting with fever and fatigue since 24 h. At presentation, he had normal clinical parameters, walking test was performed at triage showing a desaturation of three points and repeated at discharge with a two-point desaturation. Routine laboratory tests' results, blood gas analysis, lung ultrasound were normal. No patients were admitted to ICU or died during the 30 days follow-up.

In our population, around one-third of patients were safely discharged home. About 10% of patients returned to ED after a median period of 15 days (interquantile range, 8), only one had a subsequent hospital admission and no patients died. Besides the enrolment of different criteria, our population showed some similarities with another cohort recently published in an randomized clinical trial on outpatients' treatment, with a similar re-attendance rate [7] . Further larger studies are needed to establish criteria and scores that can help the clinician to safely discharge COVID-19 patients from ED.

Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region

Clinical features of 85 fatal cases of COVID-19 from Wuhan: a retrospective observational study

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

COVID-19 in critically ill patients in the Seattle region -case series

Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China

European Society For Emergency Medicine position paper on emergency medical systems' response to COVID-19

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Table 1 Clinical features of the 111 mild COVID-19 patients discharged from emergency department

There are no conflicts of interest. 18 (4) Oxygen saturation in room air, median (IQR)98 (2) COPD, chronic obstructive pulmonary disease; IQR, interquantile range.