A Retrospective Cohort Study of Clinical Factors Associated with Transitions of Care among COVID-19 Patients

Abstract

Coronavirus Disease 2019 (COVID-19) is an international health crisis. In this article, we report on patient characteristics associated with care transitions of: 1) hospital admission from the emergency department (ED) and 2) escalation to the intensive care unit (ICU). Analysis of data from the electronic medical record (EMR) was performed for patients with COVID-19 seen in the ED of a large Western U.S. Health System from April to August of 2020, totaling 10,079 encounters. Of these, 5172 resulted in admission as an inpatient within 72 h. Inpatient encounters (n = 6079) were also considered for patients with positive COVID-19 test results, of which 970 resulted in a transfer to the ICU or in-hospital mortality. Laboratory results, vital signs, symptoms, and comorbidities were investigated for each of these care transitions. Different top risk factors were found, but two factors common to hospital admission and ICU transfer were respiratory rate and the need for oxygen support. Comorbidities common to both settings were cerebrovascular disease and congestive heart failure. Regarding laboratory results, the neutrophil-to-lymphocyte ratio was associated with transitions to higher levels of care, along with the ratio of aspartate aminotransferase (AST) to alanine aminotransferase (ALT).

Health trajectories in older patients hospitalized for COVID-19: Results from the GeroCovid multicenter study

“…However, the probability of progressing towards intensive care unit admission or organ support was low and did not reach 4% even among patients who presented with severe disease needing high-flow oxygen therapy or NIV. This result differs from previous studies in younger patients, in whom greater COVID-19 severity at admission was associated with a higher probability of ICU transfer [ [13] , [14] , [15] , [16] ]. Other studies and meta-analyses showed that the progressive age-related increase in in-hospital mortality was not associated with a similar trend in ICU admission, which, instead, tended to decrease in the oldest old [ [17] , [18] , [19] , [20] ].…”

“…This point also confirmed studies that considered the impact of dependency in activities of daily living and frailty on COVID-19 outcomes [ [22] , [23] , [24] ]. Consistent with existing literature, a higher number of chronic diseases and some specific conditions, such as cerebrovascular and cardiovascular diseases, were found to be negative prognostic factors in our study [ 15 , 25 ]. In addition, depressive mood was associated with a lower chance of reverting from worse to better clinical states, in line with the pooled results of a recent meta-analysis that showed higher mortality among COVID-19 patients with mental disorders, including depression [ 26 ].…”

“…Concerning the COVID-19 course, we found that half of the sample experienced a positive course with a progressive improvement in clinical status, while almost one-third showed a gradual worsening. In keeping with previous studies [ [5] , [6] , [7] , 15 , 16 , 22 ], patients with a worse clinical course were more likely to be older, to have lower mobility levels and a higher number of chronic conditions. Interestingly, 6.4% of the sample showed a fluctuating course with both worsening and improving clinical changes during hospitalization.…”

Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Patients with COVID-19

“…Similarly, a large case–control study from the USA [ 9 ] analyzed 4103 COVID-19 patients and found that an elevated NLR (cut-off value, 5.1) was an early predictor of poor outcomes (mechanical ventilation, death or discharge to hospice). Another large retrospective cohort study from the USA [ 10 ] searched for factors associated with “care transitions” (i.e., transition from the emergency department to the inpatient floor and also to the ICU) by analyzing data from 11,406 COVID-19 patients. Among laboratory variables, the NLR was associated with transitions to higher levels of care.…”