As COVID-19 cases continue to rise across the United States, those of us in Emergency Room (ER) managing many of these patients are faced with a difficult decision every shift: “Is this patient okay for discharge?”. We know the Case Fatality Rate (CFR) of Coronavirus Disease 2019 (COVID-19) in patients aged less than 50 with no significant co-morbidities is low — but this jumps multiple fold 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 getting discharged.
On the other side, we know what to do with the patient who is hypoxic and has signs of multi organ involvement. They need to be admitted and considered for steroid and Remdesivir treatment. Again, key part here is “considered”, and based on your hospital guidelines and ever changing published literature. At a minimum, they clearly need supplemental oxygen and close monitoring for respiratory decline.
The difficult disposition cases of COVID-19 are patients who are in the gray area. Not hypoxic, but have key comorbidities, chest x-ray findings, and lab abnormalities. Many hospitals have created multidisciplinary teams and created guidelines to help their inpatient and outpatient team determine when these patients need to be managed in the acute care setting (inpatient). Unfortunately, there continues to be a paucity of rigorous evidence based tools to help determine the patient population with key clinical characteristics who will require inpatient management. However, there are emerging online resources health providers can consider using to to help with these “gray area” COVID-19 cases.
A great resource from Harvard. This Brigham and Women’s Hospital resource is the most comprehensive resource for providers in the United States. Thankfully the Harvard team created an accompanying COVID-19 medical app containing the same information. Nestled within this massive resource are some hard to find yet valuable protocols that help with COVID-19 dispositions.
COVID-19 Brigham Health ED Assessment
ED COVID-19 Disposition Assessment Algorithm (PDF)
In particular, the COVID-19 Disposition Assessment Algorithm is fantastic because it separates COVID-19 into the phases of infection, from Days 1 to 6, 7 to 11, and 12 plus. This goes into the decision making when determining if a patient can be discharged.
ACEP’s COVID-19 Severity Classification Tool
The American College of Emergency Physicians (ACEP) recently released a COVID-19 severity classification tool to help Emergency Medicine providers with disposition planning. The tool is a cumbersome 7 step process, and takes into account a combination of vitals, labs, and clinical gestalt. While cumbersome, this is a tool you could consider if you have a gray area case and you’re really perseverating on admission versus discharge.
Link: COVID-19 Severity Classification Tool
QxMD – Calculate
My favorite medical calculator app to use, our Canadian friends have a section dedicated to COVID-19 risk scores. These include but are not limited to: COVID-19 Critical Illness Prediction Tool, COVID-19 Prognostic Tool, ROX index to predict risk of intubation. I’m not a fan of their COVID-19 Prognostic Tool because the CFR data is too old now and there are updated numbers from the CDC. They have a solid collection of links within their COVID-19 section that are worth looking at as well.
Link: QxMD Calculate