How Cases of covid-19 As we continue to grow in the United States, those of us in the emergency room (ER) who manage many of these patients face a difficult decision each turn: “Is this patient okay for discharge?”. We know that the 2019 coronavirus disease mortality rate (CFR) (COVID-19) in patients under 50 years of age with no significant comorbidities is low, but this increases multiple times in subsequent decades of life. (CDC). This otherwise healthy patient population of less than 50 with reassuring vital signs is the easiest to manage. They are almost always discharged.
On the other hand, we know what to do with the patient who is hypoxic and has signs of involvement of various organs. They should be admitted and considered for treatment with steroids and Remdesivir. Again, the key part here is “considered” and based on hospital guidelines and the ever-changing published literature. At the very least, they clearly need supplemental oxygen and close monitoring of respiratory decline.
Cases of difficult disposition of COVID-19 are patients who are in the gray area. Not hypoxic, but has key comorbidities, chest X-ray findings, and laboratory abnormalities. Many hospitals have created multidisciplinary teams and created guidelines to help their inpatient and outpatient team determine when to treat these patients in the acute care setting (hospitalization). Unfortunately, there is still a shortage of rigorous evidence-based tools to help determine the patient population with key clinical features that will require hospital management. However, there are emerging online resources that healthcare providers may consider using to help with these “gray zone” COVID-19 cases.
A great Harvard resource. This Brigham and Women’s Hospital resource is the most comprehensive resource for U.S. providers. Fortunately, the Harvard team created an accompaniment COVID-19 medical application which contains the same information. Within this massive resource are some hard-to-find but valuable protocols that help with the provisions of COVID-19.
In particular, the disposition evaluation algorithm of COVID-19 is fantastic because it separates COVID-19 in the infection phases, from days 1 to 6, from 7 to 11 and 12 more. This goes into making decisions when determining whether a patient can be discharged.
ACEP COVID-19 severity classification tool
The American College of Emergency Physicians (ACEP) recently released a severity classification tool for COVID-19 to help emergency medicine providers plan the disposition. The tool is a complicated 7-step process and takes into account a combination of vital, laboratory and clinical gestalt. While it’s cumbersome, this is a tool you might consider if you have a gray area case and are really persevering in admission versus discharge.
QxMD – Calculate
My preferred medical calculator application To use, our Canadian friends have a section dedicated to COVID-19 risk scores. These include but are not limited to: Critical Disease Prediction Tool COVID-19, COVID-19 forecasting tool, ROX index to predict intubation risk. I am not a fan of your COVID-19 forecasting tool because the CFR data is now too old and there are updated CDC numbers. They have a solid collection of links within their COVID-19 section that are also worth looking at.
Link: QxMD Calculate