key: cord-0787314-8z4twsy3 authors: Berdahl, Carl T.; Glennon, Nicole C; Henreid, Andrew J; Torbati, Sam S. title: The safety of home discharge for low‐risk emergency department patients presenting with coronavirus‐like symptoms during the COVID‐19 pandemic: A retrospective cohort study date: 2020-08-17 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12230 sha: 507a17251725186a22d48d7fca62727acb2ed5dd doc_id: 787314 cord_uid: 8z4twsy3 OBJECTIVE: There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID‐19) infection who are not hospitalized. The study objective was to assess 30‐day outcomes (ED revisit, admission, ICU admission, and death) for low‐risk patients discharged after ED evaluation for COVID‐19. METHODS: This was a retrospective cohort study of patients triaged to a COVID‐19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well‐appearing with few comorbidities. Data were collected from review of medical records and phone follow‐up, and the analysis was descriptive. RESULTS: Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow‐up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3–7, range 1–17). There were no known deaths. CONCLUSIONS: A minority of low‐risk patients with suspected COVID‐19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well‐appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines. The World Health Organization has called the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic the "defining health crisis of our time." 1 After its discovery in December 2019, the virus spread to metropolitan areas across the globe, leading to early and sustained community spread in certain areas including metropolitan Los Angeles. Despite large numbers of people being infected, little work has been done to characterize outcomes among relatively low-risk patients with suspected or confirmed illness who present to the emergency department or outpatient settings. Published guidance suggests that disposition home is appropriate for patients with mild symptoms and few comborbidities. 2, 3 However, there is minimal evidence describing post-discharge outcomes for patients who are well appearing at the time of ED evaluation. Prognostic evidence from China suggests that 80% of patients have mild illness, 15% require oxygen, and 5% require ICU monitoring. 4 Currently in the United States, however, it is unknown how often patients evaluated in the ED seek subsequent care for worsening symptoms after their initial evaluation and how often they undergo monitoring in the inpatient and ICU settings. The primary goal of this investigation was to describe outcomes for low-risk patients discharged home from the ED, including rates of ED revisit, inpatient admission, and ICU admission within 30 days. Patients were selected for inclusion in the study if they were evaluated for influenza-like illness suggestive of COVID-19 in a temporary surge tent between March 12, 2020 and April 6, 2020 and discharged home. Patients were excluded from the study if they had been seen in our ED within the prior 7 days, if they did not complete ED evaluation (ie, left without being seen, left against medical advice, or eloped), or if they were asymptomatic according to clinician documentation. Patients were assessed by emergency physicians or physician assistants who were given guidelines to (1) ED administrative staff obtained data used in this study during a quality improvement initiative designed to ascertain outcomes of patients cared for in the ED's surge tent during the early COVID-19 pandemic. Data collection involved review of the electronic health record (EHR) as well as phone follow-up to patients to characterize follow-up care received and the total duration of symptoms. Data collection was performed via a combination of automatic data exportation through Epic reports (most structured data elements) and human entry into a spreadsheet (vital signs, number of days of symptoms prior to ED visit) by 2 operations team members with experience in healthcare delivery (AJH: emergency medical technician; NCG, physician assistant). These case reviews were performed as independent, unblinded reviews. One physician member of the County coroner data were queried using an online tool. Complete death certificate data were not available at the time of publication because of proximity of the visit date and preparation of the manuscript. All data were stored in a password-protected database that was maintained on an encrypted server. The primary outcomes of interest were ED revisits, inpatient admissions, ICU admissions, and deaths within 30 days of the index visit. Secondary outcomes were measured through patients' self-reported duration of symptoms including symptom onset and symptom resolution. We performed a descriptive analysis of patient and visit characteristics using STATA version 13.1 (StataCorp, College Station, TX). Additionally, 2 research team members (CTB and AJH) reviewed cases that resulted in ED revisits to determine reasons that patients cited for returning to the ED and described their findings in the supplementary appendix. The institutional review board approved this study as non-human subjects research because we utilized an already-existing ED operations database. Of 504 patients screened, 452 patients met inclusion criteria (Figure 1 The study is limited, first, by its retrospective nature and potential were not blinded to the study's intent, which may have introduced bias into assessment of those visits. Lastly, the study's generalizability to other settings is limited by the data coming from a single site. Because of site-specific characteristics, it is possible that other ED sites with different availability of access to transportation and/or those who lack medical complexity may have different rates of outcomes than our own. In this retrospective cohort study of 452 ambulatory patients with symptoms consistent with COVID-19, we provide preliminary evidence that relatively young patients with reassuring pulse oximetry, respiratory rate, general appearance, and lack of significant Median days before discharge and return for admission Missing 111 (24.6) comorbidities can self-manage their conditions outside of the hospital. Our sample had a lower rate of ED revisits compared to the 20% rate that has been published in peer-reviewed studies of all-comers to the ED. 8 Only a small proportion of our patients were hospitalized within 30 days (4.6%) and few required intensive care (0.7%). These outcomes provide preliminary evidence that relatively healthy patients tend to fare well after ED evaluation for COVID-19. The clinical progression of disease in our cohort was similar to earlier publications describing maximal symptom severity at 8-10 days after symptom onset. 9 The median interval from ED discharge to ED return of 5 days is also reassuring and argues against COVID-19 as a rapidly progressive illness or one associated with sudden onset of respiratory decompensation in younger and healthy populations. We also describe the median total duration of illness in our population to be 15 days, similar to those with "mild disease" in China. 9 Before this study, only 2 decision support tools were available to help clinicians assess the prognosis of patients with suspected viral pneumonia infection; however, neither tool is directly applicable to the US ED population during the COVID-19 pandemic. The first is the MuLBSTA score, which requires the patient to have had chest radiography (to characterize presence or absence of infiltrate) and blood work (to determine the absolute lymphocyte count) and was developed prior to the spread of COVID-19. 10 The second is the Brescia-COVID Respiratory Severity Scale, which requires serial chest radiography evaluation in patients with illness of at least 7 days and has not yet been validated outside of Italy. 11 To our knowledge, our study is the first to evaluate outcomes among ED patients with suspected COVID-19 infection in an environment in which physicians were given disposition guidelines. Of note, adherence to guidelines was not enforced nor audited. However, our clinical experience suggests that they have good face validity and could be a good candidate for formal testing in a future prospective trial. In summary, low-risk patients with suspected COVID-19 who present to the ED can be safely discharged home. Some patients will experience progression of symptoms in the ensuing week that require hospitalization for supportive therapy, typically at 10 days of symptomatic illness. ED clinicians should explain to patients that they may experience worsening symptoms after the ED visit, such as labored breathing, which should prompt them to seek follow-up assessment by a medical professional. WHO's Director General Calls on G20 to Fight, Unite, and Ignite Against COVID-19. World Health Organization Novel coronavirus 2019 (COVID-19): Emergence and implications for emergency care Coronavirus Disease (COVID-19): a primer for emergency physicians Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Clinical Management of Severe Acute Respiratory Infection When Novel Coronavirus (2019-Ncov) Infection is Suspected: Interim Guidance Revisit rates and associated costs after an emergency department encounter: a multistate analysis World Health Organization Clinical features predicting mortality risk in patients with viral pneumonia: the MuLBSTA Score Calculated decisions: Brescia-COVID Respiratory Severity Scale (BCRSS)/Algorithm Additional supporting information may be found online in the Supporting Information section at the end of the article.