key: cord-0957666-7cv4hcnv authors: Barbhaya, Dweep; Franco, Stephanie; Gandhi, Kejal; Arya, Radhika; Neupane, Rabin; Foroughi, Negar; Oluigbo, Nnenna; Fishbein, Dawn; Tran, Jennifer title: Characteristics and Outcomes of COVID-19 Infection from an Urban Ambulatory COVID-19 Clinic—Guidance for Outpatient Clinicians in Triaging Patients date: 2021-05-14 journal: J Prim Care Community Health DOI: 10.1177/21501327211017016 sha: 977b088073bde30b8f6e23c5e74cb41b74303d77 doc_id: 957666 cord_uid: 7cv4hcnv BACKGROUND: Coronavirus infection (COVID) presents with flu-like symptoms and can cause serious complications. Here, we discuss the presentation and outcomes of COVID in an ambulatory setting along with distribution of positive cases amongst healthcare workers (HCWs). METHOD: Patients who visited the COVID clinic between 03/11/2020 and 06/14/2020 were tested based on the CDC guidelines at the time using PCR-detection methods. Medical records were reviewed and captured on a RedCap database. Statistical analysis was performed using both univariate and bivariate analysis using Fischer’s exact test with 2-sided P values. RESULTS: Of the 2471 evaluated patients, 846 (34.2%) tested positive for COVID. Mean age of positivity was 43.4 years (SD ± 15.4), 60.1% were female and 49% were Black. 58.7% of people tested had a known exposure, and amongst those with exposure, 57.3% tested positive. Ninety-four patients were hospitalized (11.1%), of which 22 patients (23.4%) required ICU admission and 10 patients died. The overall death rate of patients presenting to clinic was 0.4%, or 1.2% amongst positive patients. Median length of hospital stay was 6 days (range 1-51). Symptoms significantly associated with COVID included: anosmia, fever, change in taste, anorexia, myalgias, cough, chills, and fatigue. Increased risk of COVID occurred with diabetes, whereas individuals with lung disease or malignancy were not associated with increased risk of COVID. Amongst COVID positive HCWs, the majority were registered nurses (23.4%), most working in general medicine (39.8%) followed by critical care units (14.3%). DISCUSSION/CONCLUSION: Blacks and females had the highest infection rates. There was a broad range in presentation from those who are very ill and require hospitalization and those who remain ambulatory. The above data could assist health care professionals perform a targeted review of systems and co-morbidities, allowing for appropriate patient triage. are infectious. 2 Recent reports suggest that persons may be infectious at least 1 to 3 days prior to symptom onset and that up to 40% to 50% of cases may be attributable to trans mission from asymptomatic people. 3 COVID infection is known to cause a wide range of pre sentations, from asymptomatic to severe acute respiratory distress syndrome and multiorgan dysfunction. 4 The most common features of infection are known to be fever, cough and shortness of breath. However, there is a wide range of presentations for COVID infection beyond these well described symptoms. The primary aim of this study was to investigate and characterize mild to moderate COVID infection and risk factors associated with infection and out comes. The secondary aim was to determine the risk of infection in healthcare workers amongst various depart ments and occupations. We describe the clinical presenta tions and outcomes of patients that presented to a dedicated COVID clinic in Washington, DC. 5 This study is a retrospective, single center, observational study involving a cohort of patients who were evaluated in the dedicated COVID clinic at a large, urban hospital in Washington, DC from March 11, 2020, through June 14, 2020 (when the clinic closed). We report data from 2821 patients that were evaluated in the COVID clinic. Patients from the community and hospital associates were seen in the clinic. At the time they were prescreened for symp toms, however, some patients were seen if they had COVID 19 exposure (eg from group homes, household contacts). Patients were then screened, examined and tested by nurse practitioners, physician assistants and physicians in the clinic with decisions for testing made according to CDC guidelines in place at the time of each encounter, most often only if the patient was symptomatic. Testing was conducted using PCRbased nasal swabs, both nasopharyngeal and midturbinate. Positive SARSCOV2 test results were used as a surrogate for COVID infection. Samples were pro cessed by the hospital clinical lab if the patient was an hos pital associate or by a large commercial lab if they were not an employee. A dedicated ambulatory team was assigned to calling each patient, providing test results, counseling regarding transmission and providing information on need for quarantine or isolation. Medical students and internal medicine residents col lected the following data from patients' medical records: demographics, occupation (if healthcare worker), known exposure to COVID positive contacts, comorbidities, pre senting symptoms, current medications, hospitalizations, ICU admission and death. Study data was collected and managed using REDCap electronic data capture tools hosted by MedStar Health Research Institute. 6 All patient identifiers were removed once they were entered into REDCap. The authors audited an appropriate proportion of the total abstracted data for validation and reproducibility. This study was approved by the Institutional Review Board of MedStar Health Research Institute. We also reviewed the CRISP HIE (Chesapeake Regional Information System for our Patients, Health Information Exchange) 7 that allows for patient clinical information to be shared across distinct institutional health systems to check for readmissions and/ or deaths if the patient was admitted to another hospital. Symptoms were defined as mild to moderate if the patients were sent home with symptomatic management and isolation after evaluation in the COVID clinic. Severe dis ease was defined as patients requiring hospitalization. Statistical analyses were performed using univariate analy sis using Fischer's exact test for categorical variables and Student's ttest for normally distributed continuous variables with 2sided P values. Bivariate analysis was performed to determine association between medical conditions, COVID infection and outcomes. Statistical significance was defined as a P value of <0.05. Statistical analysis was performed using SPSS and Graftpad PRISM software. A total of 2821 patients presented to the COVID clinic, of which 2471 (87.9%) were tested for SARSCoV2. Approximately onethird of patients tested were positive for COVID (n = 846 or 34.2%). The demographics of the patients are demonstrated in Table 1 . The mean age of patients with COVID was 43.4 with SD ± 15.4 years. A total of 1486 positive patients (60.1%) were female and 981 (39.7%) were male; more women tested positive (P < .001). The majority of patients who presented to the clinic were Black/African American [n = 1403 (49.7%)] of which 400 (28.5%) were found to be positive; 257 (13.0%) were Hispanic, of whom 183 (71.2%) were positive; more Hispanics than Blacks tested positive (P < .001). A history of known exposure to any confirmed case of COVID (not limited to only hospital exposure) was documented in 1650 (58.7%) of all patients, of which 485 (33.3%) were positive for COVID19. A total of 1332 (47.2%) patients were healthcare work ers, and 321 (24.1%) were found to be COVID positive; HCWs were less likely to test positive than nonHCWs (44.8%). The number of registered nurses presenting to clinic were n = 645 (26.1%) and physicians were n = 309 (12.5%). Amongst healthcare workers who were positive, the majority were registered nurses n = 75 (23.4%) followed by medical assistants/personal care technicians n = 34 (10.6%), then physicians n = 22 (6.9%) and food services employees n = 22 (6.9%). The highest number of cases were observed in healthcare workers working in general medi cine n = 314 (39.8%) followed by critical care units n = 46 (14.3%). See Figures 1 and 2 for a detailed distribution. Amongst all patients who tested positive, 101 patients (11.1%) required hospitalization after being evaluated in the ambulatory clinic. The median number of days from testing to hospitalization was 2 days (range 025), with a median length of hospital stay of 6 days (range 151). Out of the 101 patients who were hospitalized, 22 (23.4%) required ICU admission and 10 died (11%). See Table 2 . The overall mortality rate of patients presenting to COVID clinic was 0.4% and amongst all who tested positive was 1.2%. When compared to patients with negative COVID tests, the symptoms significantly associated with COVID positiv ity included ( Figure 3 Using bivariable analysis, we found that COVID infection in patients with any lung disease (excluding asthma), as well as asthma alone, was associated with cough, ED referral and hospitalization, but did not have a significant association with sore throat or shortness of breath. See Table 3 . Objective fever (OR 3.34, CI 1.14-10.89) was significantly associated with COVID infection in patients with malignancy, and all patients with malignancy that presented with anorexia had COVID infection. Patients with malignancy also had a statistically sig nificant association with hospitalization (OR 49.50, P < .001). Diabetics were more likely to be infected and hospitalized (OR 16.22, P < .001), whereas diabetes with insulin use had no significant association with COVID19 infection (OR 1.22, P = .47). Patients that presented to the clinic with lung disease and diabetes were more likely to be referred to the ED. This is a descriptive study on the epidemiology and clinical presentation of COVID in an ambulatory setting, and includes data from 2821 patients. We have compared the clinical presentation of COVID infection with other patients that had similar presentations but were PCR negative, and thus considered as not infected. Primary carelevel screen ing, triaging, referral, and emergency care of COVID19 patients in the backdrop of the current pandemic are all nec essary aspects of care. Hence, we believe that this data will help providers globally with triaging patients using predic tive symptoms and comorbidities to diagnose COVID19 early in the disease presentation. Amongst all patients who were tested in the clinic, almost 1 in 3 patients were positive for SARSCoV2, which represents a high infection rate. Of those infected, 88% of patients had mild to moderate disease and 11% of patients had severe dis ease requiring hospitalization with a median of 2 days from presentation to hospitalization. This suggests that most patients with severe disease are more likely to decompensate and become hospitalized within 2 days of presenting with symptoms and being tested (range 051 days). In those with severe disease, 23.4% required ICU admission at some point during their stay and had a median length of hospitalization of 6 days. The observed mortality rate was 11% in severe dis ease, however, overall mortality rate of all patients presenting to COVID clinic was 0.4% and amongst those who tested positive was 1.2%. The above data suggest that there is a broad gap in mortality of those who are very ill and require hospitalization to those who have mild to moderate infection and remain ambulatory. This will assist in conversations between patient and provider and will likely provide reassur ance to those who are not admitted. The majority of the patients who presented to the clinic and were positive for COVID19 infection were Black and Hispanic, which is concordant with many other studies in different cities in the United States. We believe this was contributed by multiple factors including the population distribution in Washington, DC, socioeconomic status as well as comorbidities which contributed to higher infection risk. Importantly, this highlights the racial disparities asso ciated with COVID19 infection. 8, 9 Comparison with Existing Literature We observed that mild to moderate COVID infection pre sented with the following (in order of decreasing strength of association) see Figure 3 : anosmia, subjective fever, change in taste, anorexia, objective fever, myalgias, cough, chills, fatigue/malaise and headache, and could be used as predic tive symptoms for infection. The following symptoms did not help differentiate the disease: dizziness, headache, nau sea, diarrhea, rhinorrhea, vomiting, shortness of breath, chest pain, abdominal pain, sore throat, and nasal conges tion. Apparently, shortness of breath which has been highly associated with COVID patients was not significantly asso ciated with infection in this study-perhaps patients with more severe shortness of breath presented directly to the ED. Some of the clinical manifestations of COVID infec tion were consistent with studies on COVID patients in China except lack of association for shortness of breath. 1012 More than half of all patients (58.7%) who were evalu ated at the COVID clinic had known exposure to a con firmed case of COVID (not limited to hospital COVID cases), and amongst exposed patients, onethird were COVID positive. Healthcare workers (HCWs) with known exposure had a positive rate of 23.5% (225/957). Infection rates observed in HCWs with known exposure were less when compared to nonHCWs with known exposure, which can be attributable to personal protective equipment and being more vigilant of infection control measures. Hence HCWs should continue to be vigilant about poten tial infection exposures and perhaps get tested early. Our finding are consistent with those in the review article by Bandyopadhyay et al, 13 where they found the most likely group to be affected by COVID19 were RNs and general practicioners. Nearly half of all patients (47.2%) who came to the clinic were healthcare workers, 57.3% (957) of whom had a known exposure to COVID confirmed cases. Amongst them, it was no surprise that the infection rate was highest amongst registered nurses, medical assistants and patient care technicians (PCT) as they spend most of the time with the patients in close proximity. Infection rates amongst phy sicians and food services employees was 6.9%; advanced practice clinicians was 2.8%. Clerical staff and ancillary staff constitute 5.6% of total positive HCWs each. All other departments, including administration and environmental services, accounted for less than 5% cases. Most of the workers who were infected with COVID worked in general medicine (nonintensive care unit or nonICU) floors (39.8%) followed by those working in the ICU (14.3%). Perhaps this difference between the medicine floor and crit ical care units can be explained by negative pressure rooms in the ICU, and ICU patients already being known to be infected or were patients under investigation (PUI) where full COVID precautions were implemented, and thus had a low number of missed positive cases that could have caused transmission. Infection rates in all surgical branches were *COPD was not included in the bivariate analysis as is was not statistically significant on univariate analysis. **Everyone with malignancy that had anorexia had COVID and thus there was 100% correlation. less than 4%, which is most likely secondary to the cancel lation of elective procedures during the first surge of pan demic and the redistribution of healthcare workers to medical services to care for patients. Patients with diabetes were more likely to have infection when compared to patients with other comorbidities who presented to the COVID clinic. Similarly, patients with can cer, asthma or any known lung disease were also less likely to be infected. This could possibly be explained by those patients being more vigilant about their health and respira tory symptoms leading to earlier COVID testing, and likely more social isolation. Hospitalizations were associated with comorbidies of malignancy, asthma, any lung disease and diabetes, and perhaps there was a lower threshold for admis sion by the ED. These patients should remain more vigilant and seek care earlier in their disease. The OpenSAFELY database shows that COVID19 related deaths were associ ated with most of the comorbidities, however the data was for hospitalized patient (severe disease). 14 Similar findings were reported by Deng et al 15 for COVID19 related deaths in hospitalized patients. We have found no other study with similar data to ours in an ambulatory setting. A limitation of this study is that it is a single site study with a significant proportion of patients being healthcare work ers and patients who were symptomatic being predomi nantly tested. This was inline with the CDC recommendations at the time and we cannot comment on asymptomatic infected patients. This may make the results less generaliz able to the entire population. However, we believe that this would provide a good representation of the disease in other large urban medical centers in the United States, where there will usually be a large proportion of healthcare work ers being tested. Another limitation of this study was that some cases had incomplete documentation of the exposure history, occupation and race/ethnicity. While exposure his tory and occupation depended on the healthcare provider for collection, race/ethnicity was usually captured by cleri cal front desk staff, and was limited by the race/ethnicity choices available in the electronic health record. Given that this was retrospective, we do not have morbidity or mortal ity followup data on the patients' who were not hospital ized. However the advantage of our study was that CRISP was reviewed to determine if hospitalization/mortality occurred outside of our hospital network. Based on the above data, we recommend that patients pre senting to clinic that are: female, over 45 years of age, have a known exposure to COVID, are healthcare workers, are diabetic or have renal disease are higher risk for worse outcomes and should be instructed to be more vigilant about their symptoms and be given early referrals for monoclonal antibodies or other available outpatient treatment: However, if the patient is hemodynically unstable or has severe respi ratory symptoms then referral to the emergency department would be appropriate. Those with more risk factors have a higher likelihood of being COVID19 positive. When patients present with following symptoms they should be presumed COVID19 positive until otherwise disproven by testing: anosmia, subjective/objective fevers, change in taste, anorexia, myalgias, cough, chills and fatigue. COVID has spread rapidly since it was first identified and has been shown to have a wide spectrum of severity. COVID infection was identified in almost 1 out of 3 patients who had a known exposure to COVID infection. The data from this study could assist outpatient health care profes sionals perform a targeted review of systems and comor bidities, allowing for more appropriate patient triage. It can provide guidance for clinicians in determining patient need and eligibility for available therapies, such as monoclonal antibody infusions. This work will also help healthcare workers maintain their own health and safety, especially as RNs, MAs and PCTs working in general medicine and criti cal care units, which are at highest risk and need to be remain vigilant of PPE and standard precautions. Future studies should include derivation of risk prediction models, along with clinical decision support tools for clinicians and HCWs. This pandemic has had an impact on the world in a rapid, universal, and powerful way, exposing deficiencies in both the resiliency of healthcare systems and the dissemina tion of best practices during an evolving crisis. The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Dawn Fishbein has served on a Gilead Advisory Board regarding HCV. However, No external funding for this COVID research was received. The author(s) received no financial support for the research, authorship, and/or publication of this article. Ethics approval was obtained from MedStar Institutional Review Board. No informed consent was needed as the data collection involved chart review and all patient identifier, if any collected, were removed. Dweep Barbhaya Coronavirus disease 2019 (COVID19) in the U.S. cen ters for disease control and prevention Asymptomatic and presymptomatic SARSCoV2 infections in residents of a long term care skilled nursing facility Temporal dynamics in viral shedding and transmissibility of COVID19 WHO. Report of the WHOChina joint mission on coronavirus disease 2019 (COVID19). 2020. Accessed July 9 Mild or moderate Covid 19 Research electronic data capture (REDCap)-a metadata driven methodology and workflow process for providing translational research informatics support Improve outcomes and enhance the patient experience Racial and ethnic disparities in COVID19 -related infections, hospitalizations, and deaths Is ethnicity linked to incidence or outcomes of covid19? A comprehensive literature review on the clinical presentation, and management of the pandemic coronavirus disease 2019 (COVID19) Epidemiological and clini cal characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Clinical features of patients infected with 2019 novel coronavirus in Wuhan Infection and mortality of healthcare workers worldwide from COVID 19: a systematic review Factors asso ciated with COVID19related death using OpenSAFELY Clinical determinants for fatality of 44,672 patients with COVID19 Data supporting our findings can be found through the correspond ing author: Dweep Barbhaya (dweepbarbhaya@gmail.com).