key: cord-0992457-j654lnk7
authors: Ramakrishnan, Aditi; Zreloff, Jennifer; Moore, Miranda A; Bergquist, Sharon H; Cellai, Michele; Higdon, Jason; O’Keefe, James B; Roberts, David; Wu, Henry M
title: Prolonged Symptoms after COVID-19 Infection in Outpatients
date: 2021-02-02
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofab060
sha: 8c05f8419868a62677c21eb4926b62ec66bdc16c
doc_id: 992457
cord_uid: j654lnk7

We review 127 encounters for PCR-confirmed COVID-19 infection at a multidisciplinary outpatient clinic. We describe the symptomatology, time-course, exam, and radiographic findings in this population. Patients with COVID-19 can experience persistent symptoms, primarily respiratory in nature, which can be severe enough to warrant hospitalization.

M a n u s c r i p t

Despite reports of prolonged symptoms resulting from coronavirus disease 2019 (COVID-19), literature describing its natural history is limited, particularly among outpatients. 1 Studies of persistent symptoms have focused on discharged hospitalized patients, 2 or have relied on surveys, [3] [4] rather than formal medical evaluations. Data suggest that 10% of patients can experience symptoms, such as dyspnea and fatigue, three weeks after acute illness. 4 We describe patients evaluated at an outpatient clinic during various stages of illness after the diagnosis of COVID-19.

The Emory Acute Respiratory Clinic (ARC) was initiated in April, 2020 by the Divisions of General Internal Medicine and Infectious Diseases for patients with confirmed or suspected COVID-19. The ARC was created following recognition that local case rates in the Atlanta metropolitan area were rapidly increasing, and an outpatient facility was urgently needed to decompress the demand on emergency departments (EDs) to evaluate persons with known or suspected COVID-19. A primary care suite, temporarily idled due to the shutdown of in-person visits, was selected as the initial ARC site. The site was selected for specific qualities that would facilitate infection control and patient disposition, including an isolated location away from other patient care areas, direct patient access from a parking lot away from common areas, and a location adjacent to the hospital campus with wheelchair access to the ED. Providers were recruited from primary care and infectious diseases staff, and nursing staff were provided by numerous departments across the health system experiencing decreased clinical volume due to reduction in clinical services during this period. All staff were trained in operating procedures adapted for COVID-19 from those originally developed for evaluation of persons under investigation for Ebola virus disease in the outpatient setting. 5 Patients calling our health system for COVID-19 testing or care for symptoms related to confirmed or suspected illness were triaged to the ARC if they were determined by nursing staff to have symptoms requiring an inperson evaluation (including dyspnea, chest tightness, wheezing, or weakness) but without severity A c c e p t e d M a n u s c r i p t requiring ED-level care. Patients evaluated at the ARC who were determined by their provider to need ED-or inpatient-level care were immediately transferred to the ED or hospital.

A retrospective chart review was performed of patients seen from April 3 through May 16, 2020 with confirmed COVID-19, defined as a positive reverse transcription-polymerase chain reaction (RT-PCR) assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) conducted prior to the encounter or on a specimen collected during the visit. Encounters without RT-PCR confirmation of infection were excluded from the analysis. Encounters were classified as acute, subacute, or convalescent depending on the duration since symptom onset (less than one, one to four, or greater than four weeks). Demographic and clinical data were analyzed with standard descriptive statistics. For symptoms, examination findings, disposition, and other encounter-specific data, the analysis considered multiple encounters by the same patient as separate encounters.

Among 404 consecutive patient encounters between April 3 and May 16, 127 (31.4%) had confirmed disease (107 unique patients with one to four visits, Table 1 ). One in five patients were healthcare workers, and nearly half were black patients. Ten patients were known to be previously hospitalized. Patients presented up to 96 days from symptom onset and during acute, subacute, and convalescent stages (15.7%, 58.3%, and 26.0%, respectively; Table 2 ). In most convalescent encounters, symptoms were characterized as worse or persistent.

Though measured or subjective fever was reported in 60% of acute encounters, it was less common in subacute and convalescent stages. Cough was reported in nearly 75% of encounters across all stages, while dyspnea on exertion was more common during subacute and convalescent stages.

Smell or taste alteration was present in approximately half of acute and subacute visits, but only in a quarter of convalescent encounters. Lung auscultation was largely normal during all stages. When measured, resting pulse oximetry was less than 95% oxygen saturation in 11% of cases. Infiltrates were reported in less than one third of 64 chest radiographs performed. Electrocardiography was A c c e p t e d M a n u s c r i p t performed in 15 (11.8%) of encounters, with only two studies illustrating acute changes with tachycardia.

About half of encounters had one or more secondary diagnoses, including a variety of respiratory and other conditions ( Table 2) . A diagnosis of secondary bacterial pneumonia was made in 8.7% of encounters. Although most patients were discharged home, direct transfers from the ARC to the ED or inpatient ward occurred in 17.3% of all encounters and were most prevalent among subacute visits. Reasons for transfers to the ED or hospital included hypoxia (68.2%), dyspnea without hypoxia (22.7%), chest pain (4.5%), and asthma exacerbation (4.5%).

Following acute illness, patients with COVID-19 can experience significant prolonged symptoms. Increasing awareness of chronic symptoms has led to new terminology such as "post-acute COVID-19" and "long-haulers." 1, 6 Although respiratory symptoms were common in our patients across all stages of illness, we found abnormalities in lung auscultation, pulse oximetry, and chest radiography in only a minority of patients. However, illness in over 17% of encounters was concerning enough to warrant transfer to the ED or hospital. Furthermore, in over half of the encounters, there were one or more secondary diagnoses, including numerous respiratory and cardiovascular conditions which may have resulted from COVID-19 or exacerbated the symptoms.

Because the typical course can vary among patients of different ages and medical backgrounds, our experience may differ from clinics caring for other populations. As our study is also limited to the outpatient encounter, we cannot assess complications diagnosed after the visit.

Although RT-PCR is considered the most sensitive test for diagnosing acute illness, it is also likely some patients with COVID-19 infection were excluded from our analysis due to false-negative results or clearance of viral shedding in patients tested after the acute period. Further study of the prevalence, pathophysiology, and treatment of persistent symptoms in COVID-19 is needed. Although the second wave of the US pandemic affected many younger patients, typically with mild illness, the potential for prolonged and debilitating symptoms is concerning 6, 10 . As the US is in the midst of the third wave, health systems must creatively adapt existing resources to manage the increasing numbers of patients in all stages of illness. M a n u s c r i p t M a n u s c r i p t 

Management of post-acute covid-19 in primary care

Persistent Symptoms in Patients after Acute COVID-19

Symptom Duration and Risk Factors for Delayed Return to Usual Health among Outpatients with COVID-19 in a Multistate Health Care Systems Network -United States

How long does COVID-19 last? Kings College London

The Potential Ebola-Infected Patient in the Ambulatory Care Setting: Preparing for the Worst Without Compromising Care

As Their Numbers Grow, COVID-19 "Long Haulers" Stump Experts

Treatment Guidelines. The COVID-19 Treatment Guidelines Panel's Statement on the Emergency Use Authorization of Bamlanivimab for the Treatment of COVID-19

Treatment Guidelines. The COVID-19 Treatment Guidelines Panel's Statement on the Emergency Use Authorization of Casirivimab Plus Imdevimab Combination for the Treatment of COVID-19

A Proposed Framework and Timeline of the Spectrum of Disease due to SARS-CoV-2 Infection: Illness beyond Acute Infection and Public Health Implications