key: cord-0820046-3dklzhec
authors: Tobolowsky, Farrell A.; Bardossy, Ana C.; Currie, Dustin W.; Schwartz, Noah G.; Zacks, Rachael L.T.; Chow, Eric J.; Dyal, Jonathan W.; Ali, Hammad; Kay, Meagan; Duchin, Jeffrey S.; Brostrom-Smith, Claire; Clark, Shauna; Sykes, Kaitlyn; Jernigan, John A.; Honein, Margaret A.; Clark, Thomas A.; Stone, Nimalie D.; Reddy, Sujan C.; Rao, Agam K.
title: Signs, Symptoms, and Comorbidities Associated with Poor Outcomes among Residents of a Skilled Nursing Facility with SARS-CoV-2 Infection—King County, Washington
date: 2021-01-28
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.01.070
sha: eb9332f8d717d570aa2be93f352a365aa71f2a74
doc_id: 820046
cord_uid: 3dklzhec

Background Effective halting of outbreaks in Skilled Nursing Facilities (SNFs) depends on the earliest recognition of cases. We assessed confirmed COVID-19 cases at a SNF impacted by COVID-19 in the United States to identify early indications of COVID-19 infection. Methods We performed retrospective reviews of electronic health records for residents with laboratory-confirmed SARS-CoV-2 during February 28–March 16, 2020. Records were abstracted for co-morbidities, signs and symptoms, and illness outcomes during the two weeks before and after the date of positive specimen collection. Relative Risks (RR) of hospitalization and death were calculated. Results Of the 118 residents tested among approximately 130 residents from Facility A during February 28 – March 16, 2020, 101 (86%) were found to test positive for SARS-CoV-2. At initial presentation, about two thirds of SARS-Cov-2-positive residents had an abnormal vital sign or change in oxygen status. Most (90.2%) symptomatic residents had elevated temperature, change in mental status, lethargy, change in oxygen status, or cough; nine (11.0%) did not have fever, cough, or shortness of breath during their clinical course. Those with change in oxygen status had an increased relative risk of 30-day mortality (51.1% vs. 29.7%, RR: 1.7 [1.0-3.0]). RR of hospitalization was higher for residents with underlying hepatic disease (1.6 [95% CI: 1.1-2.2]) or obesity (1.5 [95% CI: 1.1-2.1]); RR of death was not statistically significant. Conclusions and implications Our findings reinforce the critical role that monitoring of signs and symptoms can have in identifying COVID-19 cases early. SNFs should ensure they have a systematic approach for responding to abnormal vital signs and oxygen saturation and consider ensuring common signs and symptoms identified in Facility A are among those they monitor.

Background: Effective halting of outbreaks in Skilled Nursing Facilities (SNFs) depends on the 2 earliest recognition of cases. We assessed confirmed COVID-19 cases at a SNF impacted by 3 COVID-19 in the United States to identify early indications of Methods: We performed retrospective reviews of electronic health records for residents with 5 laboratory-confirmed SARS-CoV-2 during February 28-March 16, 2020. Records were 6 abstracted for co-morbidities, signs and symptoms, and illness outcomes during the two weeks 7 before and after the date of positive specimen collection. Relative Risks (RR) of hospitalization 8 and death were calculated. were conducted in accordance with CDC guidelines 7 . Diagnostic testing was done using the 65 CDC's SARS-CoV-2 real-time reverse transcription polymerase chain reaction (rRT-PCR) panel for 66 detection of SARS-CoV-2 8 . 67 We defined a case as a patient with laboratory-confirmed SARS-CoV-2 among residents 68 of Facility A during February 28-March 16, 2020. We performed a retrospective review of 69 electronic health records for the two weeks before and the two weeks after the date of positive 70 specimen collection to capture signs and symptoms associated with COVID-19. The electronic 71 health records were reviewed to obtain the needed information including admission and daily 72 clinical progress notes, recorded vital signs and oxygen saturation, medication orders, and 73 active medical diagnoses. Demographics, comorbidities, body mass index (BMI), objective signs 74 and symptoms, and scheduled medications while at Facility A were abstracted; BMI ≥ 30 kg/m 2 75 was defined as obese and medications abstracted included β-Hydroxy β-methylglutaryl-CoA 76 (HMG-CoA)reductase inhibitors, angiotensin converting enzyme (ACE) inhibitors, angiotensin-77 receptor blockers (ARB), narcotics, and immunosuppressive medications such as chemotherapy 78 and corticosteroids. 79 We defined asymptomatic infected patients as those residents with a positive SARS- CoV-2 test for whom we did not find documented evidence of signs and symptoms consistent 81 with COVID-19 in the two weeks before or after the positive test was performed, and we 82 J o u r n a l P r e -p r o o f defined pre-symptomatic infected patients as residents without symptoms at the time of 83 specimen collection who developed symptoms in the two weeks after. Asymptomatic residents 84 and those with unknown illness onset date were excluded from analysis of signs and symptoms. 85 We defined illness onset date as the first day of any of the following: elevated temperature, 86 change in oxygen status, or any new symptom in the two weeks before or after testing positive 87 for COVID-19 while at Facility A. Change in oxygen status was defined as a decrease of three 88 percent or more from baseline oxygen saturation, a new supplemental oxygen requirement, or 89 a decrease in oxygen saturation to below 90 percent. Tachycardia was defined as heart rate 90 above 90 beats per minute, tachypnea as respiratory rate above 20 breaths per minute, 91 elevated temperature as any temperature above 99 degrees Fahrenheit, low grade fever as a calculate P-values, which were not adjusted for multiple comparisons due to the exploratory 105 nature of the study. Risk ratios were calculated as the ratio of the proportion exposed with 106 outcome to proportion unexposed with outcome, with 95% confidence intervals being 107 calculated using the Taylor Series method. Risk ratios with confidence intervals that did not 108 cross 1.0 and P-values ≤ 0.05 were considered statistically significant. Analysis was performed 109 using SAS 9.4. This activity was conducted as part of a public health response and was therefore 110 deemed non-human subjects research by CDC. for fever and symptoms and ill residents, which includes evaluating vital signs, symptoms, and 214 respiratory exam including oxygen saturation, at least three times a day 3 . Some elderly 215 residents may not experience the typical symptoms of COVID-19 such as fever, shortness of 216 breath, or cough and may not exhibit any respiratory symptoms at all 11, 12 . Persons with 217 dementia pose an additional challenge to SNFs because these residents may be unable to 218 reliably convey symptoms to caregivers 11 . 219 We found that only chronic hepatic disease, obesity, and receiving treatment with CPAP 220 use were associated with statistically significant increased risk for hospitalization; each of these 221 increased risk of hospitalization between 50-60%. Other studies specific to hospitalized patients 222 have shown that older age, hypertension, diabetes, cardiovascular disease, and respiratory 

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