Utility Of An Emergency Department Clinical Protocol For Early Identification of Coronavirus Infection

Abstract

Introduction We assessed the utility of an emergency department (ED) protocol using clinical parameters to rapidly distinguish likelihood of novel coronavirus 2019 (COVID-19) infection; the applicability aimed to stratify infectious-risk pre-polymerase chain reaction (PCR) test results and accurately guide early patient cohorting decisions. Methods We performed this prospective study over a two-month period during the initial surge of the 2020 COVID-19 pandemic in a busy urban ED of patients presenting with respiratory symptoms who were admitted for in-patient care. Per protocol, each patient received assessment consisting of five clinical parameters: presence of fever; hypoxia; cough; shortness of breath/dyspnea; and performance of a chest radiograph to assess for bilateral pulmonary infiltrates. All patients received nasopharyngeal COVID-19 PCR testing. Results Of 283 patients studied, 221 (78%) were PCR+ and 62 (22%) PCR-. Chest radiograph revealed bilateral pulmonary infiltrates in 85%, which was significantly more common in PCR+ (94%) vs PCR- (52%) patients (P < 0.0001). The rate of manifesting all five positive clinical parameters was significantly greater in PCR+ (63%) vs PCR- (6.5%) patients (P < 0.0001). For PCR+ outcome, the presence of all five positive clinical parameters had a specificity of 94%, positive predictive value of 98%, and positive likelihood ratio of 10. Conclusions Using an ED protocol to rapidly assess five clinical parameters accurately distinguishes likelihood of COVID-19 infection prior to PCR test results, and can be used to augment early patient cohorting decisions.

Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis

“…Several groups have proposed distinguishing COVID-19 positive from negatives based on a combination of symptoms and other clinical parameters. [ 1 , 11 ] Bonadio et al, [ 1 ] used symptoms, oxygen saturation and a chest radiograph to identify patients with COVID-19. The inclusion of the radiograph is problematic in busy EDs due to the time required to obtain and interpret images.…”

“…In March 2020, COVID-19 surged in New York City, presenting numerous challenges for Emergency Departments (EDs). [ 1 ] Once the initial spike had passed, a continuing challenge has been how to minimize nosocomial spread of COVID-19 in crowded urban EDs given the limited physical space and resources to provide isolation. Although interventions such as masking can reduce the spread of COVID-19, [ 2 ] this intervention is often not practical among a population of ED patients with acute illness particularly those with respiratory symptoms.…”