Association of Initial Clinical Characteristics with the Need for the Intensive Care Unit and Hospitalization in Patients Presenting to the Emergency Department with Acute Symptomatic COVID-19

  1. Benjamin Zollinger
  2. Sophia Newton
  3. Jincong Q. Freeman
  4. Seamus Moran
  5. Nataly Montano Vargas
  6. Yan Ma
  7. Andrew C. Meltzer

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Abstract

Objective

To evaluate the association of initial clinical symptoms with need for hospitalization, intensive care, or death in ED patients within 30 days after presenting with acute symptomatic COVID-19.

Methods

This study is a retrospective case-series of patients presenting to a single ED with acute symptomatic COVID-19 from March 7–August 9, 2020. Symptomatic patients with laboratory-confirmed SARS-CoV-2 infection were eligible for this study. Patients who tested positive for COVID-19 due to screening tests but had no reasonably associated symptoms were excluded. Participants were analyzed by three categories representative of clinical severity: intensive care unit (ICU) care/death, general ward admission, and ED discharge/convalescence at home. Outcomes were ascertained 30 days after initial presentation to account for escalation in severity after the ED visit. We conducted univariate and multivariable logistic regression analyses to report odds ratios (OR) with 95% confidence intervals (CI) between hospital or ICU care/death versus convalescence at home and between ICU care/death versus general ward admission.

Results

In total, 994 patients were included in the study, of which, 551 (55.4%) patients convalesced at home, 314 (31.6%) patients required general ward admission, and 129 (13.0%) required ICU care or died. In the multivariable models, ED patients requiring hospital admission were more likely to be aged ≥ 65 years (adjusted OR [aOR] 7.4, 95% CI: 5.0, 10.8), Black/African American (aOR 3.0, 95% CI: 1.6, 5.8) or Asian/American Indian/Alaska Native/Other (aOR 2.2, 95% CI: 1.1, 4.3), and experience dyspnea (aOR 2.7, 95% CI: 2.0, 3.7) or diarrhea (aOR 1.6, 95% CI: 1.1, 2.2). However, they were less likely to experience sore throat (aOR 0.4, 95% CI: 0.2, 0.6), myalgia (aOR 0.5, 95% CI: 0.4, 0.7), headache (aOR 0.5, 95% CI: 0.4, 0.8), or olfactory/taste disturbance (aOR 0.5, 95% CI: 0.3, 0.8). ED patients who required ICU care or died were more likely to experience altered mental status (aOR 3.8, 95% CI: 2.1, 6.6), but were less likely to report history of fever (0.5, 95% CI: 0.3, 0.8).

Conclusions

COVID-19 presents with a multitude of clinical symptoms and an understanding of the association of symptoms with clinical severity may be useful for predicting ultimate patient outcomes.

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  1. ScreenIT

    SciScore for 10.1101/2021.09.19.21263800: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: The protocol was approved by the Institutional Review Board at George Washington University with a waiver of consent on March 30, 2020. 2.2 Study Population: Patients with a positive nasopharyngeal swab for SARS-CoV-2 by polymerase chain reaction (PCR) on an index ED visit or within 14 days prior to the ED visit were included in this analysis.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    All data was entered into a secure REDCap database.
    REDCap
    suggested: (REDCap, RRID:SCR_003445)
    We completed all analyses using SAS 9.4 (SAS Institute, Cary, NC).
    SAS Institute
    suggested: (Statistical Analysis System, RRID:SCR_008567)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    4.1 Strengths/Limitations: Strengths of our study include a high quality chart review for all of the patients included in the study, along with a 30 day buffer period after the patients’ index ED presentation to check for any subsequent admissions, re-admissions, or worsening clinical course. We reclassified patients into different severity categories based on worsening disease course and the requirement of elevated levels of care. This helps to account for the unpredictable clinical course that COVID-19 may assume in different patients. Furthermore, the three categories of severity are pragmatic as they are the three most common dispositions for patients after ED evaluation and as such, are based on the needs of the patient. Although the three categories are delineated along the three strata of patient care, one limitation of the study is that the categories of severity were still dependent on individual physician decision regarding the necessary level of care. Due to the fluctuating prevalence of COVID-19 patients over the course of the pandemic, this decision may also have been influenced by hospital system factors such as crowding or surges in the patient census. Furthermore, due to the evolving clinical care and guidance over the year of the pandemic, there may have been shifting standards for admission. Our study was a single-center retrospective study, so there may be variation in generalization to other institutions due to different patient populations or institutiona...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2021.09.19.21263800v1 on medRxiv