ABSTRACT
Background: With the rapid spread of SARS-CoV-2 across the globe, numerous authors have noted different patient characteristics that may relate to an increased admission rate to an intensive care unit (ICU). However, little data has been presented comparing these characteristics among those who receive care at either a rural or urban emergency department (ED). Study Objective: To compare the clinical characteristics and outcomes of patients with COVID-19 admitted to the ICU from rural and urban EDs. Methods: A retrospective, multi-center cohort study of adult patients who required hospitalization between March 01, 2020 and July 01, 2020 due to confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection from two rural and one urban ED in Arizona were included in analysis. Research assistants who were blinded to the study hypothesis were trained on proper data abstraction prior to the collection of data by the study team. With adherence to a quality-controlled protocol and structured abstraction tool, research assistants manually collected patient demographics, ED laboratory values, initial vital signs, total hospitalizations, ICU admissions, and mortality in a with a one-to-one allocation ratio non-White and White patients. Comparisons of the comorbidities among patients transferred to the ICU in urban and rural hospitals were conducted with the chi-squared analysis. Factors that may predict transfer to the ICU were determined via a stepwise multivariable binomial logistic regression. Results: A total of 304 patients (175 urban and 129 rural) with confirmed SARS-CoV-2 infection were admitted to the hospital during the study period with 63 patients (24 urban vs 39 rural;OR=2.1, p=0.01) being admitted to the ICU. Of those admitted to the ICU, a total of 21 (33.3%) were female (11 urban and 10 rural). The median age of patients admitted to the ICU from the urban cohort was 66.0 years old (IQR=35.0) and from the rural cohort was 62.6 years (IQR=28).The most common comorbidity seen in both urban and rural patients admitted to the ICU was hypertension (12 [50%] urban;21 [53.8%] rural). In the overall cohort, multivariable logistic regression showed an increase in the odds of ICU admission among patients presenting with concurrent bacterial infection (p=0.043), elevated temperature (p=0.002), respiratory rate (p=0.003), white blood cells (p=0.034), and reduced hemoglobin levels (p=0.014). Across the total cohort, these factors predicted transfer to the ICU with a sensitivity of 39.5% and specificity of 95.2%. Conclusion: Patients with confirmed SARS-CoV-2 are more likely to require critical care intervention if presenting to the emergency department with concurrent bacterial infection, elevated temperature, respiratory rate, white blood cells, and reduced hemoglobin. The degree to which these factors generalize between urban and rural hospitals remains to be elucidated.
ABSTRACT
Background: Although over half of all counties in the United States are classified as rural, less than 20% of the population live in rural areas. Those who live in rural areas have been shown to have a higher mortality rate from heart disease, cancer and cerebral vascular accidents as compared to their urban counterparts. However, no data is currently available for those with COVID-19. Study Objective: To describe and compare the clinical characteristics and outcomes of patients with COVID-19 who presented to rural and urban emergency departments (ED). Methods: A retrospective, multi-center cohort study of adult patients who required hospitalization between March 01, 2020 and July 01, 2020 due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was conducted. All data was abstracted from two rural and one urban ED in Arizona. Research assistants who were blinded to the study hypothesis were trained on proper data abstraction prior to collection. With adherence to a quality-controlled protocol and structured abstraction tool, research assistants manually collected patient demographics, intake laboratory values, initial vital signs, ICU admissions, and mortality. Data was collected using a one-to-one allocation ratio based upon ethnicity for each site. Comparisons between rural and urban populations were completed using chi-square, Mann-Whitney U, and independent samples T-tests. Results: A total of 304 patients (175 urban and 129 rural) with confirmed SARS-CoV-2 infection were admitted to the hospital during the study period. Patients presenting to a rural ED were more likely to be admitted to the ICU (24 urban vs 39 rural;OR = 2.1;p=0.01). Of those hospitalized, a total of 137 (43.9%) were female (87 [47.5%] urban and 50 [38.8%] rural). The median age of patients hospitalized from the urban cohort was 67 years old (IQR=25) and from the rural cohort was 63 years (IQR=28).Of those studied, 43 (14.1%) patients expired from COVID-19 with 24 (13.1%) patients in the urban cohort and 19 (14.7%) in the rural cohort (p=0.06). Those in the rural population presented to the ED 7.0 (IQR 7) days from initial symptoms onset and those in the urban population 5 (IQR 4) (p=0.005). Patients treated at urban EDs had a higher systolic blood pressure (138.6 mmHg vs 130.3 mmHg;p=0.01) but lower oxygen saturation (91.7% vs 93.1%;p=0.04) than those treated at a rural ED. When intake laboratory values were considered, patients treated in an urban ED had a statistically significant lower white blood cell count and ferritin level as compared to those at a rural ED but a higher hemoglobin, hematocrit, and calcium level (Table). Conclusion: Rural patients with COVID-19 exhibit a delay in presentation to their local ED, producing atypical prognostic laboratory measures when compared to urban centers. This delay may contribute to symptom exacerbation and a higher rate of critical care admissions among rural patients. [Formula presented]