The safety of home discharge for low‐risk emergency department patients presenting with coronavirus‐like symptoms during the COVID‐19 pandemic: A retrospective cohort study

Abstract

Objective There is minimal evidence describing outcomes for emergency department (ED) patients with suspected coronavirus disease 2019 (COVID‐19) infection who are not hospitalized. The study objective was to assess 30‐day outcomes (ED revisit, admission, ICU admission, and death) for low‐risk patients discharged after ED evaluation for COVID‐19. Methods This was a retrospective cohort study of patients triaged to a COVID‐19 surge area within an urban ED and discharged between March 12 and April 6. Physicians were encouraged to discharge patients if they were well‐appearing with few comorbidities. Data were collected from review of medical records and phone follow‐up, and the analysis was descriptive. Results Of 452 patients, the median age was 38, and 61.7% had no comorbidities. Chest radiographs were performed for 50.4% of patients and showed infiltrates in 14% of those tested. Polymerase chain reaction testing was performed for 28.3% of patients during the index ED visit and was positive in 35.9% of those tested. Follow‐up was achieved for 75.4% of patients. ED revisits occurred for 13.7% of patients. The inpatient admission rate at 30 days was 4.6%, with 0.7% requiring intensive care. Median number of days between index ED evaluation and return for admission was 5 (interquartile range 3–7, range 1–17). There were no known deaths. Conclusions A minority of low‐risk patients with suspected COVID‐19 will require hospitalization after being discharged home from the ED. Outpatient management is likely safe for well‐appearing patients with normal vital signs, but patients should be instructed to return for worsening symptoms including labored breathing. Future work is warranted to develop and validate ED disposition guidelines.

Validation of home oxygen saturations as a marker of clinical deterioration in patients with suspected COVID-19

“…Although oxygen saturations as a risk factor for COVID-19 patients on presentation to the Emergency Department are widely reported,[13, 14] [15] the ability of oxygen saturations measured at home to indicate disease severity and the need for hospital conveyance has not been widely reported, presumably because of the challenges in equipping patients with pulse oximeters prior to the onset of any illness. Several studies have used oxygen levels in patients presenting in the Emergency Department as an indicator of the need for hospital admission and others have used the opportunity to send ED patients not requiring admission home with a pulse oximeter for self-monitoring.…”

“…[14] Other studies have shown that even a relatively mildly deranged oxygen saturation of <92% is strongly associated with an increased risk of in-hospital mortality. [16] Conversely, an Emergency Department resting SpO 2 ≥ 92% as part of discharge criteria can achieve hospital readmission rates as low as 4.6%, [15] suggesting that it may be a safe threshold for discharge in symptomatic patients with mild disease.…”

Using body temperature and variables commonly available in the EHR to predict acute infection: A proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients

“…Study procedures involved accessing an existing operational database to collect variables characterizing: patient age, sex, vital signs (including date, time, and route of measurement), comorbidities, and COVID-19 PCR test results from nasal swab samples. [12] Additionally, the content of physician and physician assistant notes describing patients’ visits was reviewed.…”

Discharge from the Emergency Department and Early Hospital Revaluation in Patients with COVID-19 Pneumonia: an Observational Study

“…Indeed, one of the crucial decisions is the discharge from the Emergency Department (ED). In a retrospective cohort of low-risk patients (median age 38 and 61% without comorbidities) with COVID19-like symptoms discharged from ED, the readmission rate was 4% after a median of 5 days [6]. In a multicentre study enrolling only con rmed COVID-19 patients, about 5% of patients discharged from ED was readmitted, and then hospitalized, within 72 hours and 8.2% within seven days; the major predictors of readmission were the presence of hypoxia, fever and age > 60 years [7].…”

“…Two-thirds of patients had at least one comorbidity and 41.6% had a lung involvement > 25% at HRCT; the mean duration of symptoms was 8 ± 3 days and the mean PaO2/FiO2 ratio 357.5 ± 38. 6. At the end of the follow-up period, 69 patients had been discharged and 15 hospitalized (mean stay 6 days).…”