Discharge in Pandemic: Suspected Covid-19 patients returning to the Emergency Department within 72 hours for admission

Abstract

Introduction: Coronavirus disease 2019 (Covid-19) has led to unprecedented healthcare demand. This study seeks to characterize Emergency Department (ED) discharges suspected of Covid-19 that are admitted within 72 h.

Methods: We abstracted all adult discharges with suspected Covid-19 from five New York City EDs between March 2nd and April 15th. Those admitted within 72 h were then compared against those who were not using descriptive and regression analysis of background and clinical characteristics.

Results: Discharged ED patients returning within 72 h were more often admitted if suspected of Covid-19 (32.9% vs 12.1%, p < .0001). Of 7433 suspected Covid-19 discharges, the 139 (1.9%) admitted within 72 h were older (55.4 vs. 45.6 years, OR 1.03) and more often male (1.32) or with a history of obstructive lung disease (2.77) or diabetes (1.58) than those who were not admitted (p < .05). Additional associations included non-English preference, cancer, heart failure, hypertension, renal disease, ambulance arrival, higher triage acuity, longer ED stay or time from symptom onset, fever, tachycardia, dyspnea, gastrointestinal symptoms, x-ray abnormalities, and decreased platelets and lymphocytes (p < .05 for all). On 72-h return, 91 (65.5%) subjects required oxygen, and 7 (5.0%) required mechanical ventilation in the ED. Twenty-two (15.8%) of the study group have since died.

Conclusion: Several factors emerge as associated with 72-h ED return admission in subjects suspected of Covid-19. These should be considered when assessing discharge risk in clinical practice.

Keywords: Clinical decision-making; Coronavirus; Disaster medicine; Emergency medicine; Pandemics; Patient discharge.

Fig. 1

ED volume by disposition during the Covid-19 pandemic, with the stacked area plot (leftward axis) demonstrating trends in discharges and admissions over time with suspicion (dotted and striped, respectively) and without suspicion (grey and dark grey, respectively) for Covid-19. Overlying is a line graph (rightward axis) depicting those publicly available confirmed daily cases in New York City, as of May 14th.

Fig. 2

Consort flow diagram demonstrating derivation of the study group of those suspected Covid-19 ED discharges returning within 72 h for hospital admission, the control group of those suspected Covid-19 discharges not returning within 72 h for admission, and the nested control group for direct comparison of various clinical features of the first hospital encounter. Excluded were 19 ED discharges with discrepant visit timelines that were either erroneously duplicated or should have been treated as continuous encounters.