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Objective: The pandemic of coronavirus disease (COVID-19) has rapidly spread globally and infected millions of people. The prevalence and prognostic impact of dysnatremia in COVID-19 is inconclusive. Therefore, we investigated the prevalence and outcome of dysnatremia in COVID-19. Design: The prospective, observational, cohort study included consecutive patients with clinical suspicion of COVID-19 triaged to a Swiss Emergency Department between March and July 2020. Methods: Collected data included clinical, laboratory and disease severity scoring parameters on admission. COVID-19 cases were identified based on a positive nasopharyngeal swab test for SARS-CoV-2, patients with a negative swab test served as controls. The primary analysis was to assess the prognostic impact of dysnatremia on 30-day mortality using a cox proportional hazard model. Results: 172 (17%) cases with COVID-19 and 849 (83%) controls were included. Patients with COVID-19 showed a higher prevalence of hyponatremia compared to controls (28.1% vs. 17.5%, p<0.001); while comparable for hypernatremia (2.9% vs 2.1%, p=0.34). In COVID-19 but not in controls, hyponatremia was associated with a higher 30-day mortality (HR 1.4, 95%-CI 1.10-16.62, p=0.05). In both groups, hypernatremia on admission was associated with higher 30-day mortality (COVID-19: HR 11.5, 95%-CI 5.00-26.43, p<0.001; controls: HR 5.3, 95%-CI 1.60-17.64, p=0.006). In both groups, hyponatremia and hypernatremia were significantly associated with adverse outcome, e.g. intensive care unit admission, longer hospitalization, and mechanical ventilation. Conclusion: Our results underline the importance of dysnatremia as predictive marker in COVID-19. Treating physicians should be aware and appropriate treatment measures taken in patients with COVID-19 and dysnatremia.

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Frailty is a state of increased vulnerability for poor resolution of homeostasis after a stressor event, so that frail individuals are at risk for adverse health outcomes and prolonged convalescence. 1 In the emergency department (ED), triage acuity predicts the outcomes of ED length of stay, hospitalization, intensive care unit (ICU) admission, and mortality within 30 days, 2 but may be ill-suited for prediction of adverse outcomes beyond this time frame. In a large Danish study, for example, abnormal vital signs were strong risk factors for mortality within the first 2 days, but hereafter, the association declined with time from arrival most rapidly until day 7. 3 Longer term prognostication is likely more dependent on physiological reserve such as the degree of frailty rather than how ill or

This prospective observational study evaluated the safety and feasibility of a low threshold testing process in a Triage and Test Center (TTC) during the early course of the coronavirus disease 19 (COVID-19) pandemic. In addition, we aimed to identify clinical predictors for a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) swab result. Patients underwent informal triage, standardized history taking, and physician evaluation, only where indicated. Patients were observed for 30 days. Safety was the primary outcome and was defined as a COVID-19-related 30 day re-presentation rate <5% and mortality rate <1% in patients presenting to the TTC. Feasibility was defined as an overruling of informal triage <5%. Among 4815 presentations, 572 (11.9%) were tested positive for SARS-CoV-2, and 4774 were discharged. Mortality at 30-days was 0.04% (2 patients, one of which related to COVID-19). Fever (OR 2.03 [95% CI 1.70;2.42]), myalgia (OR 1.94 [1.63;2.31]), chills (OR 1.77 [1.44;2.16]), headache (OR 1.61 [1.34;1.94]), cough (OR 1.50 [1.24;1.83]), weakness (OR 1.46 [1.21;1.76]), and confusion (OR 1.39 [1.06;1.80]) were associated with test positivity. Re-presentation rate was 8% overall and 1.4% in COVID-19 related re-presentation (69 of 4774). The overruling rate of informal triage was 1.5%. According to our study, a low-threshold testing process in a TTC appeared to be safe (low re-presentation and low mortality) and is feasible (low overruling of informal triage). A COVID-19 diagnosis based on clinical parameters only does not appear possible.

Older age and frailty are predictors of adverse outcomes in patients with COVID-19. In emergency medicine, patients do not present with the diagnosis, but with suspicion of COVID-19. The aim of this study was to assess the association of frailty and age with death or admission to intensive care in patients with suspected COVID-19. This single-centre prospective cohort study was performed in the Emergency Department of a tertiary care hospital. Patients, 65 years and older, with suspected COVID-19 presenting to the Emergency Department during the first wave of the pandemic were consecutively enrolled. All patients underwent nasopharyngeal SARS-CoV-2 PCR swab tests. Patients with a Clinical Frailty Scale (CFS) > 4, were considered to be frail. Associations between age, gender, frailty, and COVID-19 status with the composite adverse outcome of 30-day-intensive-care-admission and/or 30-day-mortality were tested. In the 372 patients analysed, the median age was 77 years, 154 (41.4%) were women, 44 (11.8%) were COVID-19-positive, and 125 (33.6%) were frail. The worst outcome was seen in frail COVID-19-patients with six (66.7%) adverse outcomes. Frailty (CFS > 4) and COVID-19-positivity were associated with an adverse outcome after adjustment for age and gender (frailty: OR 5.01, CI 2.56–10.17, p < 0.001; COVID-19: OR 3.47, CI 1.48–7.89, p = 0.003). Frailty was strongly associated with adverse outcomes and outperformed age as a predictor in emergency patients with suspected COVID-19.

Background Risk stratification for older people based on aggregated vital signs lack the accuracy to predict mortality at presentation to the Emergency Department (ED). We aimed to develop and internally validate the Frailty adjusted Prognosis in ED tool (FaP‐ED) for 30‐day mortality combining frailty and aggregated vital signs. Methods Single‐center prospective cohort of undifferentiated ED patients aged 65 or older, consecutively sampled upon ED presentation from a tertiary Emergency Center. Vital signs were aggregated using the National Early Warning Score (NEWS) as a measure of illness or injury severity and frailty was assessed with the Clinical Frailty Scale (CFS). The FaP‐ED was constructed by combining NEWS and CFS in multivariable logistic regression. The primary outcome was 30‐day mortality. Measures of discrimination and calibration were assessed to evaluate predictive performance and internally validated using bootstrapping. Results 2250 patients were included, 67 (1.8%) were omitted from analyses due to missing CFS, loss to follow‐up, or terminal illness. Thirty‐day mortality rate was 5.4% (N = 122, 95% CI = 4.5%–6.4%). Median NEWS was 1 (Inter‐Quartile Range (IQR): 0–3) and median CFS was 4 (IQR: 3–5). The Area Under Receiver Operating Characteristic (AUROC) for FaP‐ED was 0.86 (95% CI = 0.83–0.90). This was significantly higher than NEWS (0.81, 95% CI = 0.77–0.85, DeLong: Z = 3.5, p < 0.001) or CFS alone (0.82, 95% CI = 0.78–0.86, DeLong: Z = 4.4, p < 0.001). Bootstrapped estimates of FaP‐ED AUROC, calibration slope, and intercept were 0.86, 0.95, and −0.09, respectively, suggesting internal validity. A decision‐threshold of CFS 5 and NEWS 3 was proposed based on qualitative comparison of positive Likelihood Ratio at all relevant FaP‐ED cutoffs. Conclusion Combining aggregated vital signs and frailty accurately predicted 30‐day mortality at ED presentation and illustrated an important clinical interaction between frailty and illness severity. Pending external validation, the Fap‐ED operationalizes the concept of such “geriatric urgency” for the ED setting.