key: cord-0845969-65qvj49h authors: Krieger, Joshua; McGuire, Flynn; Risa, Erik; Longino, August; Coppess, Steven; Riveros, Toni; Hebert, Chris; Town, James; Bhatraju, Pavan; Johnson, Nicholas title: Emergency department characteristics and associations with intensive care admission among patients with coronavirus disease 2019 date: 2021-01-14 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12350 sha: 6f880ae6e21c532d5083db8b86ddd3a50d9e4179 doc_id: 845969 cord_uid: 65qvj49h OBJECTIVE: There have been few descriptions in the literature to date specifically examining initial coronavirus disease 2019 (COVID‐19) patient presentation to the emergency department (ED) and the trajectory of patients who develop critical illness. Here we describe the ED presentation and outcomes of patients with COVID‐19 presenting during our initial local surge. METHODS: This is a multicenter, retrospective cohort study using data extracted from the electronic health records at 3 hospitals within a single health system from March 1, 2020 to June 1, 2020. Patients were included in the study if they presented to an ED and had laboratory‐confirmed severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection during the study period. Data elements were extracted from the electronic health record electronically and by trained data abstractors and entered into a secure database. We used multivariable regression analysis to examine ED factors associated with the development of critical illness and mortality, with a primary outcome of ICU admission. RESULTS: A total of 330 patients with laboratory‐confirmed SARS‐CoV‐2 infection were admitted during the study period. Of these, 112 (34%) were admitted to the ICU. Among these patients, 20% were female, 50% were White, the median age was 61 (interquartile range [IQR], 52–72), and the median body mass index (BMI) was 28.1 (IQR, 24.3–35.1). On univariable analysis, a doubling of lactate dehydrogenase (LDH) (odds ratio [OR], 3.87; 95% confidence interval [CI], 2.40–6.27) or high‐sensitivity C‐reactive protein (hsCRP; OR, 1.32; 95% CI, 1.11–1.57) above the reference range or elevated troponin (OR, 12.1; 95% CI, 1.20–121.8) were associated with ICU admission. After adjusting for age, sex, and BMI, LDH was the best predictor of ICU admission (OR, 3.54; 95% CI, 2.12–5.90). Of the patients, 15% required invasive mechanical ventilation during their hospital course, and in‐hospital mortality was 19%. CONCLUSIONS: Nearly one‐third of ED patients who required hospitalization for COVID‐19 were admitted to the ICU, 15% received invasive mechanical ventilation, and 19% died. Most patients who were admitted from the ED were tachypneic with elevated inflammatory markers, and the following factors were associated with ICU admission: elevated hsCRP, LDH, and troponin as well as lower oxygen saturation and increased respiratory rate. After adjusting for age, sex, and BMI, LDH was the best predictor of ICU admission (OR, 3 .54; 95% CI, 2. 12-5.90 ). Of the patients, 15% required invasive mechanical ventilation during their hospital course, and in-hospital mortality was 19%. Conclusions: Nearly one-third of ED patients who required hospitalization for COVID- 19 were admitted to the ICU, 15% received invasive mechanical ventilation, and 19% died. Most patients who were admitted from the ED were tachypneic with elevated inflammatory markers, and the following factors were associated with ICU admission: elevated hsCRP, LDH, and troponin as well as lower oxygen saturation and increased respiratory rate. The early history of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been well described. [1] [2] [3] Early articles from Italy, China, Washington State, and New York State established a wide clinical picture of SARS-CoV-2 infection and critical illness. [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] Most of these studies were broad and focused on the clinical course of patients with COVID-19 from hospital admission to discharge or death. The first confirmed case in the United States was in Seattle, WA, in January 2020. Few studies of earlier cohorts focused on the initial emergency department (ED) presentation of patients with COVID-19 and its relationship to outcomes. Here, in a cohort of patients who presented to our EDs during the peak of our inpatient volume in the spring of 2020, we describe the ED-presenting characteristics as well as the risk factors associated with ICU admission and in-hospital mortality. Our primary objective is to characterize the cohort of patients presenting to EDs in our hospital system with COVID-19. We also investigate associations between demographics, ED triage vital signs, initial ED laboratory values, and outcomes. Our primary outcome measure is ICU admission. Because of ICU and acute care ward parameters, we could reasonably assume that certain triage vital sign abnormalities, including significant tachypnea, hypotension, and severe hypoxemia, would predict ICU admission. Given other reports associating elevated markers of inflammation with ICU admission and mortality, 16, 17 we hypothesized that laboratory markers of inflammation, including an elevated d-dimer and high-sensitivity C-reactive protein (hsCRP), would also be associated with ICU admission. We also hypothesized that a respira-tory rate > 22 and blood oxygen saturation < 95% at triage would be associated with mortality. This was a retrospective cohort study of all patients seen in the emergency department from March 1, 2020, to June 14, 2020 who had a positive SARS-CoV-2 polymerase chain reaction (PCR) test and were admitted to the hospital. This study was conducted at 3 hospitals within a single health system, consisting of a quaternary university hospital, an urban county-owned trauma center, and an academic-affiliated community hospital with more than 100,000 combined ED visits annually. EDs within our system occasionally use high flow nasal cannula, and most patients requiring more than 6 L of supplemental oxygen will be admitted to an ICU. A respiratory rate > 34 also mandates an ICU admission rather than an acute care service admission. We electronically abstracted data from the electronic health record for all patients with SARS-CoV-2 detected on PCR from nasopharyngeal swabs or lower respiratory tract samples. We included only patients who had an ED visit at 1 of the study hospitals, and we counted separate ED visits from the same patient as unique encounters. We included all patients who were admitted. All charts from patients admitted to the ICU were manually reviewed by medical students, critical care fellows, and critical care faculty trained in data abstraction and verified to meet inclusion criteria. Agreement between several key data elements (selected a priori and found in the Supplementary Appendix) that were abstracted both electronically and manually were assessed using κ scores to ensure accuracy of the abstraction processes. We collected demographics, vital signs, and selected initial laboratory results in the ED. We also gathered the initial and final levels of respiratory support provided in the ED. Missing data were excluded from the analyses, and the relevant sample numbers are reported in the tables. Our laboratory uses the Beckman High Sensitivity Troponin assay with a normal range of < 0.04 ng/mL. We use an optical assay to detect d-dimer with a normal range of < 0.59 mcg/mL of fibrinogen-equivalent units. We use the LX1 immuno-turbidemetry assay to detect hsCRP with a normal range of < 10 mg/L. Our exposures of interest, determined a priori, were demographics Our primary outcome was ICU admission during the index hospital- Univariate statistics including frequency counts and percentages were used to describe the baseline characteristics of the study population. Characteristics of the groups who were and were not admitted to the ICU were compared and described using the the remainder of the demographics are presented in Table 1 . Data gathered during the ED visits are presented in Table 2 . Notably, 35% of patients had an initial respiratory rate > 21 breaths per minute, and 27% of patients were hypoxemic with initial oxygen saturation < 95%. Only 8.6% of all patients were febrile on presentation. Of the patients, 10% were leukopenic with a WBC count < 4.6 × 10 9 cells/L, and 13% of patients had a leukocytosis with WBC counts > 11.9 × 10 9 cells/L. Of 271 patients who had a troponin checked, 80% of the results were elevated > 0.03 ng/mL, and 45% of the patients had an elevated d-dimer > 1 mcg/mL. Of the patients, 85% had a hsCRP > 10 mg/L. The mean hsCRP and LDH were higher than the reference range across the entire cohort. In our cohort, 112 (33.9%) patients were admitted to the ICU during their hospitalization. We performed univariable analyses of initial ED laboratory values, vital signs, and BMI and present the findings in We found that 51 ( We performed the same univariable analysis as noted previously for in-hospital mortality, and these results are presented in Table 7 . An elevated WBC count, an elevated hsCRP, and an elevated lymphocyte count were predictive of mortality. The κ values for agreement between electronic and manual abstrac- This is a retrospective cohort study, and therefore we cannot comment on causation, only association. Certain data elements were not reliably available for all patients, and missing data may have biased our results. Although we report good agreement between manual and electronic abstraction for selected data elements, we did not manually verify all electronically abstracted data. We did count patients with multiple ED visits as separate encounters, which we felt was justified because patients present at different stages of their disease course, but which could bias our results. Our sample size is small, and we report only data from the earliest phase of the pandemic. ED clinicians had guidance suggesting elevated inflammatory markers may confer a worse prognosis, and triage decisions could have been influenced by this among other presenting characteristics. The characteristics of affected patients may have changed as the pandemic has grown and our results may be less applicable. We report the characteristics and associated outcomes of patients seen in the EDs in our hospital system during the initial phase of the COVID-19 pandemic in Seattle. Common ED findings among patients who required hospital admission were as follows: the typical patient was normotensive, afebrile, and not hypoxemic. Tachypnea is a common finding among previous cohorts, and patients in our cohort presented to the ED with an average respiratory rate of 21. 7,8,12,32 Nonspecific markers of inflammation were frequently elevated and myocardial injury as evidenced by an elevated troponin was common. On univariable and multivariable analyses, a doubling of LDH or hsCRP above the reference ranges (210 U/L and 10 mg/L, respectively) as well as increased respiratory rate and decreased SpO2 were associated with ICU admission. The finding of elevated inflammatory markers correlating with ICU admission and mortality are consistent with prior reports, both from earlier outbreaks and later in the pandemic. 8, 12, 16, 17, [32] [33] [34] [35] We found that vital signs were strong predictors of ICU admission, but not of mortality. In ours and in many systems, certain vital sign parameters mandate ICU admission or will trigger rapid responses on acute care wards. Patients may have presented tachypneic or tachycardic and thus required ICU admission, but those vital signs in the ED did not predict death in our cohort. It is possible that the value in predicting critical illness and mortality in patients with COVID-19 lies not in triage decisions in the ED, but in deciding who should be given which therapeutics and when. Triage decisions to ICUs will have to account for vital signs, which are not strongly associated with mortality. Laboratory markers of inflammation, on the other hand, may reflect host immune response and are consistently associated with mortality. We report a higher proportion of patients who were admitted to the ICU than prior cohorts. 5, 7, 9, 11 Given that our mortality rate was similar to prior cohorts, this is likely a reflection of our hospital system during the time these data were gathered. 7 7 This was much higher than 2 large cohorts from China reporting 2% to 3% requiring invasive mechanical ventilation, 9, 11 but lower than the 71% reported in a small early case series of critically ill patients in Wuhan. 6 Again, here we refer to our hospital system to explain the likely differences. We were able to provide high flow nasal oxygen to patients we judged did not yet require invasive mechanical ventilation, and we were never overwhelmed. Our inpatient mortality rate of 19.1% is consistent with previous cohorts ranging from 0% to 39%. 5, [7] [8] [9] 30 As noted previously, there are likely many factors responsible for these differences. Overwhelmed systems might have allocated scarce resources and personnel differently from ours, resulting in different outcomes. Interestingly, our hospital mortality rate of 19% exceeds the proportion of patients who received invasive mechanical ventilation (15.5%). Many of our system's first patients came from large outbreaks in nursing homes, and different goals of care of these patients could account for this finding, as evidenced by the lower adjusted mortality rate after removing patients whose first code status was DNR/DNI and who died (15.2%). Other patients may have chosen to pursue comfort-focused rather than lifeprolonging treatment later in their hospitalization before being intubated. Among patients admitted to an ICU, we report a mortality rate of 30%, similar to a nationwide cohort of patients in the United States admitted to ICUs during a similar time frame as our study. 30 Nearly one-third of ED patients who required hospitalization for COVID-19 were admitted to the ICU, 15.5% received invasive mechanical ventilation, and 19% died. Most patients who were admitted from the ED were tachypneic with elevated inflammatory markers, and the following factors were associated with ICU admission: elevated hsCRP, LDH, and troponin as well as lower oxygen saturation and increased respiratory rate. These laboratory parameters may help in the initial risk stratification of patients with COVID-19, but this requires prospective study. Nicholas Johnson, Pavan Bhatraju, and James Town conceived and designed the study. All authors participated in manual data abstraction. Flynn McGuire, Erik Risa, and Pavan Bhatraju performed the statistical analyses. Joshua Krieger, Flynn McGuire, and Nicholas Johnson drafted the article, and all authors contributed substantially to its revision. Joshua Krieger takes responsibility for the paper as whole. The authors declare no conflict of interest. The novel coronavirus originating in Wuhan, China: challenges for global health governance First Case of 2019 Novel Coronavirus in the United States The species Severe acute respiratory syndromerelated coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2 Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention Clinical findings of patients with coronavirus disease 2019 in Jiangsu province, China: a retrospective, multicenter study Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study Clinical characteristics of Coronavirus Disease 2019 in China Clinical characteristics of patients who died of Coronavirus Disease 2019 in China Clinical characteristics and outcomes of hospitalised patients with COVID-19 treated in Hubei (epicentre) and outside Hubei (non-epicentre): a nationwide analysis of China Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region Covid-19 in critically ill patients in the Seattle Region -Case Series Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State Clinical course and factors associated with hospitalization and critical illness among COVID-19 patients in Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease Clinical care guidance for healthcare professionals about coronavirus (COVID-19) Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome Prone positioning in severe acute respiratory distress syndrome Neuromuscular blockers in early acute respiratory distress syndrome Early Neuromuscular blockade in the acute respiratory distress syndrome Formal guidelines: management of acute respiratory distress syndrome Extracorporeal life support organization COVID-19 interim guidelines Hydrocortisone therapy for patients with septic shock Adjunctive Glucocorticoid therapy in patients with septic shock Hydrocortisone plus Fludrocortisone for adults with septic shock Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies Factors associated with death in critically ill patients with Coronavirus Disease 2019 in the US Interrater reliability: the kappa statistic Exploiting an early warning Nomogram for predicting the risk of ICU admission in patients with COVID-19: a multi-center study in China Scoring systems for predicting mortality for severe patients with COVID-19 Prediction model and risk scores of ICU admission and mortality in COVID-19 Characterization of the inflammatory response to severe COVID-19 illness Joshua Krieger, MD, is an emergency medicine-trained fellow in critical care medicine at the University of Washington who hopes to continue a career upstairs and downstairs after graduating.His interests include improving the efficiency of care delivery and extracorporeal membrane oxygenation. Additional supporting information may be found online in the Supporting Information section at the end of the article.