Characterisation of 22445 patients attending UK emergency departments with suspected COVID-19 infection: Observational cohort study

Abstract

Background Hospital emergency departments play a crucial role in the initial assessment and management of suspected COVID-19 infection. This needs to be guided by studies of people presenting with suspected COVID-19, including those admitted and discharged, and those who do not ultimately have COVID-19 confirmed. We aimed to characterise patients attending emergency departments with suspected COVID-19, including subgroups based on sex, ethnicity and COVID-19 test results. Methods and findings We undertook a mixed prospective and retrospective observational cohort study in 70 emergency departments across the United Kingdom (UK). We collected presenting data from 22445 people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020. Outcomes were admission to hospital, COVID-19 result, organ support (respiratory, cardiovascular or renal), and death, by record review at 30 days. Mean age was 58.4 years, 11200 (50.4%) were female and 11034 (49.6%) male. Adults (age >16 years) were acutely unwell (median NEWS2 score of 4), frequently had limited performance status (46.9%) and had high rates of admission (67.1%), COVID-19 positivity (31.2%), organ support (9.8%) and death (15.5%). Children had much lower rates of admission (27.4%), COVID-19 positivity (1.2%), organ support (1.4%) and death (0.3%). Similar numbers of men and women presented to the ED, but men were more likely to be admitted (72.9% v 61.4%), require organ support (12.2% v 7.7%) and die (18.2% v 13.0%). Black or Asian adults tended to be younger than White adults (median age 54, 50 and 67 years), were less likely to have impaired performance status (43.1%, 26.8% and 51.6%), be admitted to hospital (60.8%, 57.3%, 69.6%) or die (11.6%, 11.2%, 16.4%), but were more likely to require organ support (15.9%, 14.3%, 8.9%) or have a positive COVID-19 test (40.8%, 42.1%, 30.0%). Adults admitted with suspected and confirmed COVID-19 had similar age, performance status and comorbidities (except chronic lung disease) to those who did not have COVID-19 confirmed, but were much more likely to need organ support (22.2% v 8.9%) or die (32.1% v 15.5%). Conclusions Important differences exist between patient groups presenting to the emergency department with suspected COVID-19. Adults and children differ markedly and require different approaches to emergency triage. Admission and adverse outcome rates among adults suggest that policies to avoid unnecessary ED attendance achieved their aim. Subsequent COVID-19 confirmation confers a worse prognosis and greater need for organ support. Registration ISRCTN registry, ISRCTN56149622, http://www.isrctn.com/ISRCTN28342533.

Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19: The PRIEST observational cohort study

“…The sample size was dependent on the size and severity of the pandemic, but based on a previous study in the 2009 H1N1 influenza pandemic we estimated we would need to collect data from 20,000 patients across 40–50 hospitals to identify 200 (1%) with an adverse outcome, giving sufficient power for model derivation. In the event, the adverse outcome rate in adults was much higher in the COVID-19 pandemic (22%) [ 7 ], giving us adequate power to undertake derivation and validation of triage tools to predict all three outcomes.…”

“…The United Kingdom (UK) Department of Health and Social Care activated PRIEST on 20 March 2020 to develop and evaluate triage tools in the COVID-19 pandemic. Initial descriptive analysis of the PRIEST data showed that adults presenting to the ED with suspected COVID-19 have much higher rates of COVID-19 positivity, hospital admission and adverse outcome than children [ 7 ]. We therefore decided to undertake separate studies in adults and children, and only develop a new triage tools in adults, which we present here.…”

Do Not Attempt Resuscitation (DNAR) status in people with suspected COVID-19: Secondary analysis of the PRIEST observational cohort study

“…We only included patients who were admitted to hospital after ED assessment because DNAR planning was considered unlikely to be routinely undertaken for discharged patients and would be limited to a minority of highly selected cases. We also only included adults (age ≥ 16 years) because previous analysis [15] showed that children with suspected COVID-19 had very low rates of confirmed COVID-19 or adverse outcome.…”

“…The Pandemic Respiratory Infection Emergency System Triage (PRIEST) study was established to develop and evaluate triage tools for people presenting to hospital emergency departments with suspected COVID-19. [15] DNAR status was recorded to facilitate evaluation of triage tools in pre-specified subgroups. We present a post hoc secondary analysis of patients admitted with suspected COVID-19 that aims to describe their characteristics and outcomes according to their DNAR status and identify factors associated with recording of a DNAR decision.…”

Modelling of hypothetical SARS-CoV-2 point-of-care tests on admission to hospital from A&E: rapid cost-effectiveness analysis

“…The probability that a patient admitted to hospital has clinical symptoms indicative of COVID-19 is conditional on whether the patient has or has not been infected with SARS-CoV-2. For patients hospitalised because of a SARS-CoV-2 infection, the proportion with clinical symptoms was set at 95.5% using the value reported by Docherty et al 9 We estimated the proportion of patients who have not been infected with SARS-CoV-2 but who nevertheless have symptoms indicative of COVID-19 using data presented in Goodacre et al 6 and Docherty et al 9 Goodacre et al 6 provide the number of patients admitted to hospital who are suspected of having COVID-19 based on clinical assessment that noted that the diagnostic criteria for COVID-19 at the time the data were collected were fever (i.e. temperature of ≥ 37.8°C) and presence of at least one of a number of clinical conditions that had to be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing or sneezing.…”