A 4C mortality score based dichotomic rule supports Emergency Department discharge of COVID-19 patients.

BACKGROUND: For COVID-19 patients evaluated in the Emergency Department (ED), decision on hospital admission vs home discharge is challenging. The 4C mortality score (4CMS) is a prognostication tool integrating key demographic/clinical/biochemical data validated for COVID-19 inpatients. We sought to derive and validate a dichotomic rule based on 4CMS identifying patients with mild outcomes, suitable for safe ED discharge. METHODS: Derivation was performed in a prospective cohort of ED patients with suspected COVID-19 from two centers (April 2020). Validation was pursued in a prospective multicenter cohort of ED patients with confirmed COVID-19 from 6 centers (October 2020 to January 2021). Chest x-ray (CXR) images were independently scored. The primary composite outcome was all-cause 30-day mortality or hospital admission. Secondary outcomes were ED re-visit, oxygen therapy and ventilation. RESULTS: In a derivation cohort of 838 ED patients with suspected COVID-19, 4CMS ≤8 was associated with low outpatient mortality (0.4%) and was thus selected as a feasible discharge rule. In a validation cohort of 521 COVID-19 outpatients, the mean age was 51±17 years; 97 (18.6%) patients had ≥1 CXR infiltrate. The 4CMS had an AUC of 0.82 for the primary outcome and 0.93 for mortality, outperforming other scores (CURB-65, qCSI, qSOFA, NEWS) and CXR. In 474 (91%) patients with 4CMS≤8, the mortality rate was 0.2% and the hospital admission rate was 6.8%, versus 12.8% and 36.2% for 4CMS≥9 (P<0.001). CXR did not provide additional discrimination. CONCLUSIONS: COVID-19 outpatients with 4CMS≤8 have mild outcomes and can be safely discharged from the ED. [NCT0462918].

Lung Ultrasound Improves Outcome Prediction over Clinical Judgment in COVID-19 Patients Evaluated in the Emergency Department.

In the Emergency Department (ED), the decision to hospitalize or discharge COVID-19 patients is challenging. We assessed the utility of lung ultrasound (LUS), alone or in association with a clinical rule/score. This was a multicenter observational prospective study involving six EDs (NCT046291831). From October 2020 to January 2021, COVID-19 outpatients discharged from the ED based on clinical judgment were subjected to LUS and followed-up at 30 days. The primary clinical outcome was a composite of hospitalization or death. Within 393 COVID-19 patients, 35 (8.9%) reached the primary outcome. For outcome prognostication, LUS had a C-index of 0.76 (95%CI 0.68-0.84) and showed good performance and calibration. LUS-based classification provided significant differences in Kaplan-Meier curves, with a positive LUS leading to a hazard ratio of 4.33 (95%CI 1.95-9.61) for the primary outcome. The sensitivity and specificity of LUS for primary outcome occurrence were 74.3% (95%CI 59.8-88.8) and 74% (95%CI 69.5-78.6), respectively. The integration of LUS with a clinical score further increased sensitivity. In patients with a negative LUS, the primary outcome occurred in nine (3.3%) patients (p < 0.001 vs. unselected). The efficiency for rule-out was 69.7%. In unvaccinated ED patients with COVID-19, LUS improves prognostic stratification over clinical judgment alone and may support standardized disposition decisions.

After the first wave and beyond lockdown: long-lasting changes in emergency department visit number, characteristics, diagnoses, and hospital admissions.

The first wave (FW) of COVID-19 led to a rapid reduction in total emergency department (ED) visits and hospital admissions for other diseases. Whether this represented a transient "lockdown and fear" phenomenon, or a more persisting trend, is unknown. We divided acute from post-wave changes in ED flows, diagnoses, and hospital admissions, in an Italian city experiencing a FW peak followed by nadir. This multicenter, retrospective, cross-sectional study involved five general EDs of a large Italian city (January-August 2020). Percent changes were calculated versus 2019, using four 14-day periods (FW peak, early/mid/late post-wave). ED visits were 147,446 in 2020, versus 214,868 in 2019. During the FW peak, visits were reduced by 66.4% (P < 0.001). The drop was maximum during daytime (69.8%) and for pediatric patients (89.4%). Critical triage codes were unchanged. Reductions were found for all non-COVID-19 diagnoses. Non-COVID-19 hospital admissions were reduced by 39.5% (P < 0.001), involving all conditions except hematologic, metabolic/endocrine, respiratory diseases, and traumas. In the early, mid, and late post-wave periods, visits were reduced by 25.4%, 25.3% and 23.5% (all P < 0.001) respectively. In the late period, reduction was greater for female (27.9%) and pediatric patients (44.6%). Most critical triage codes were unchanged. Oncological, metabolic/endocrine, and hematological diagnoses were unchanged, while other diagnoses had persistent reductions. Non-COVID-19 hospital admissions were reduced by 12.8% (P = 0.001), 6.3% (P = 0.1) and 12.2% (P = 0.001), respectively. Reductions in ED flows, led by non-critical codes, persisted throughout the summer nadir of COVID-19. Hospital admissions for non-COVID-19 diseases had transient changes.