Streamlining Patient Management of Suspected COVID-19 Patients in the Emergency Department: Incorporation of Pulmonary CT Angiography into the Triaging Algorithm.

Purpose: To evaluate the use of pulmonary computed tomography (CT) angiography during initial admission at an emergency department (ED), to identify COVID-19 patients with accompanying pulmonary embolism (PE) and its impact on clinical management. Methods: We performed a retrospective analysis of COVID-19 patients that underwent pulmonary CT angiography at the ED. CT scans were evaluated for the presence and extent of PE and for imaging changes suspicious of COVID-19. Patients were subdivided into two groups: (1) Group A consisted of patients with proven COVID-19 based on real-time polymerase chain reaction (RT-PCR), and (2) Group B of patients suspected for COVID-19, comprising patients positive on RT-PCR and/or COVID-19-suspicious CT findings. To assess the differences between patients with and without pulmonary embolism, Fisher's exact test was used. Results: A total of 308 patients were admitted to the ED for diagnostic work-up of dyspnea and suspected COVID-19, and 95 patients underwent pulmonary CT angiography. PE was detected in 13.6% (3/22) of patients in Group A and 20.7% (6/29) in Group B. No significant differences were observed between patients with and without PE concerning hospitalization (Group B: 100% (6/6) vs. 91.3% (21/23)), the necessity of oxygen therapy (Group B: 66% (4/6) vs. 43.5% (10/23)), and death (Group B: 33% (2/6) vs. 4.3% (1/23) p > 0.05, respectively). Conclusions: In 20.7% of COVID-19 patients, PE was detected upon admission to the ED. Although the incorporation of early pulmonary CT angiography in patients suspicious of COVID-19 may be beneficial to identify concomitant PE, further studies are necessary to corroborate these findings.

[Risk management in the triage of emergency room patients to outpatient care : Manchester Triage System and CEReCo-blue as a tool for low-risk patient management in integrated emergency centers]. / Risikomanagement in der Triage ambulanter Notfallpatienten : Manchester Triage System und CEReCo-blue als Instrument zur risikoarmen Patientensteuerung in integrierten Notfallzentren.

BACKGROUND: So-called "integrated emergency centers (IEC)" are going to be implemented in German hospitals and will be the first contact point in the emergency care setting. For early decision-making whether outpatient care or inpatient admission in the emergency department is indicated, it would be helpful to have a system to identify patients for outpatient treatment. In this study, we investigated whether the Manchester Triage System (MTS) is suitable for identifying patients who can be safely referred to emergency room patients to outpatient care. METHODS: Patients in the emergency department of the "blue" MTS level were examined for the endpoint inpatient admission and were compared with the next higher MTS category "green". In a second step, the "blue" MTS category was examined for the most common criteria leading to inpatient admission. RESULTS: After excluding patients who were presented by the emergency medical services (EMS) or after prior medical consultation, the rate of inpatient admissions in the blue MTS category was significantly lower than in the green category (10.8% vs 29.0%). The rate could be reduced to 0.9% by establishing a subgroup with the additional exclusion criteria chronic disorder and readmission after prior inpatient treatment (CEReCo-blue group: Chronic Disorder (C), Emergency Medical Service (E), Readmission (R), Prior Medical Consultation (Co)). CONCLUSION: The blue MTS category does not appear to be suitable for the selection of patients with indication for outpatient treatment. We propose the introduction of a subgroup, the so-called CEReCo-blue group, which could be helpful for the selection of this patient group.

Proximity to COVID-19 on Mental Health Symptoms among Hospital Medical Staff.

BACKGROUND: Exposure to patients with COVID-19 can have a significant impact on mental health of hospital medical staff. The aim of this study was to examine the influence of proximity to patients with COVID-19 considering occupational position and gender on the mental health of hospital staff. SUBJECTS AND METHODS: N=78 participants were included in the study, with n=40 of them with direct contact to patients with COVID-19 (51%); eight had contact with patients suspected of having COVID-19 (10%), and n=30 with no direct contact to people with COVID-19 (39%). RESULTS: Multinomial regression analyses showed that proximity had a negative (inverse) influence on avoidance behaviour as part of PTSD, physical symptoms, somatization, compulsiveness and anger expression-in as tendency to suppress anger. In addition, there was a significant impact of the female gender on increased physical symptoms, while age, work experience and occupation had no further influence. CONCLUSIONS: These results that hospital medical staff is less psychologically stressed when closer to COVID-19 patients are inconsistent with previous studies. Self-efficacy and locus of control in these situations are relevant for processing the trauma. In summary, perception of personal risk is essential. Proximity is believed to be a proxy variable for personal risk perception. As a synopsis of these results, regular briefings of the hospital staff are recommended to prevent psychological impairment. They should contain specific information about conditions in the affected wards and the risk of infection, which could help reduce risk perception of medical personnel.

What about the others: differential diagnosis of COVID-19 in a German emergency department.

BACKGROUND: The ongoing COVID-19 pandemic remains a major challenge for worldwide health care systems and in particular emergency medicine. An early and safe triage in the emergency department (ED) is especially crucial for proper therapy. Clinical symptoms of COVID-19 comprise those of many common diseases; thus, differential diagnosis remains challenging. METHOD: We performed a retrospective study of 314 ED patients presenting with conceivable COVID-19 symptoms during the first wave in Germany. All were tested for COVID-19 with SARS-Cov-2-nasopharyngeal swabs. Forty-seven patients were positive. We analyzed the 267 COVID-19 negative patients for their main diagnosis and compared COVID-19 patients with COVID-19 negative respiratory infections for differences in laboratory parameters, symptoms, and vital signs. RESULTS: Among the 267 COVID-19 negative patients, 42.7% had respiratory, 14.2% had other infectious, and 11.2% had cardiovascular diseases. Further, 9.0% and 6.7% had oncological and gastroenterological diagnoses, respectively. Compared to COVID-19 negative airway infections, COVID-19 patients showed less dyspnea (OR 0.440; p = 0.024) but more dysgeusia (OR 7.631; p = 0.005). Their hospital stay was significantly longer (9.0 vs. 5.6 days; p = 0.014), and their mortality significantly higher (OR 3.979; p = 0.014). CONCLUSION: For many common ED diagnoses, COVID-19 should be considered a differential diagnosis. COVID-19 cannot be distinguished from COVID-19 negative respiratory infections by clinical signs, symptoms, or laboratory results. When hospitalization is necessary, the clinical course of COVID-19 airway infections seems to be more severe compared to other respiratory infections. TRIAL REGISTRATION: German Clinical Trial Registry DRKS, DRKS-ID of the study: DRKS00021675 date of registration: May 8th, 2020, retrospectively registered.

SARS-CoV-2 rapid antigen test: Fast-safe or dangerous? An analysis in the emergency department of an university hospital.

The use of Antigen point of care tests (AgPOCT) might be an essential tool to fight the coronavirus disease 2019 (COVID-19) pandemic. Manufacturer information indicates a specificity of about 95% and there is a growing interest to use these tests area-wide. Therefore, it is necessary to clarify whether AgPOCT can be used safely for "rule-in" (detection of positive patients) and for "rule-out" (valid negative testing). Two thousand three hundred and seventy-five patients received polymerase chain reaction (PCR) testing and AgPOCT for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) regardless of symptoms. The positive predictive value of symptomatic and asymptomatic patients was compared with a cut-off threshold cycle (C t ) value of ≤30 and in total. Five hundrded and fifty-one patients tested positive for the SARS-CoV-2 virus by PCR, of whom 35.2% presented without symptoms. In all patients, regardless of their symptoms or C t values, a sensitivity of 68.9% and a specificity of 99.6% were calculated for AgPOCT. In patients with C t values ≤30, a sensitivity of 80.5% (95% confidence interval: ±1.62) and a specificity of 99.6% were shown for all tests (symptomatic/asymptomatic). Highly infectious patients (C t ≤ 20), regardless of symptoms, were reliably detected by the AgPOCT. In infectious patients with C t values ≤30, the test has a sensitivity of about 80% regardless of COVID-19 typical symptoms, which is apparently less than the 96.52% specificity indicated by the manufacturer. Relevant improvement in test sensitivity by querying the patients who are symptomatic and asymptomatic is also not feasible. We strongly suggest that we critically question the use of AgPOCT for "rule-out," as they only provide a supposed safety.

Separating the wheat from the chaff-COVID-19 in a German emergency department: a case-control study.

BACKGROUND: COVID-19 pandemia is a major challenge to worldwide health care systems. Whereas the majority of disease presents with mild symptoms that can be treated as outpatients, severely ill COVID-19 patients and patients presenting with similar symptoms cross their ways in the emergency department. Especially, the variety of symptoms is challenging with primary triage. Are there parameters to distinguish between proven COVID-19 and without before? How can a safe and efficient management of these inpatients be achieved? METHODS: We conducted a retrospective analysis of 314 consecutive inpatient patients who presented with possible symptoms of COVID-19 in a German emergency department between March and April 2020 and were tested with a SARS-Cov-2 nasopharyngeal swab. Clinical parameters, Manchester Triage System categories, and lab results were compared between patients with positive and negative test results for SARS-Cov-2. Furthermore, we present the existing COVID-19 workflow model of the university hospital in Essen which proved to be efficient during pandemia. RESULTS: Forty-three of the 314 patients (13.7%) were tested positive for COVID-19 by SARS-Cov-2 nasopharyngeal swab. We did not find any laboratory parameter to distinguish safely between patients with COVID-19 and those with similar symptoms. Dysgeusia was the only clinical symptom that was significantly more frequent among COVID-19 patients. CONCLUSION: Dysgeusia seems to be a typical symptom for COVID-19, which occurred in 14% of our COVID-19 patients. However, no valid parameters could be found to distinguish clinically between COVID-19 and other diseases with similar symptoms. Therefore, early testing, a strict isolation policy, and proper personal protection are crucial to maintain workflow and safety of patients and ED staff for the months to come. TRIAL REGISTRATION: German Clinical Trials registry, DRKS00021675.

Effective intranasal cooling in an 80 year old patient with heatstroke.

Intranasal cooling by the evaporation of perflourcarbon is almost exclusively used for the induction of therapeutic hypothermia in post-resuscitation care. This method has proven to be effective and safe. This case presents a successful application to a patient with external heatstroke. The 80 year old male patient was found in deep coma (GCS 4) by emergency medical services (EMS) showing a core temperature around 42 °C. Despite of preclinical physical cooling, the patient showed a persistent temperature of 41.5 °C upon reaching the emergency department. After endotracheal intubation intranasal evaporation cooling was performed and the patient's core temperature was reduced efficiently. We recorded an excellent cooling rate of 2.8 °C per hour. 16 h later the patient was successfully extubated with a good neurological outcome. This case shows that although intranasal cooling is mostly known for post-resuscitation care, there is a sensible application in heatstroke with imminent cerebral oedema.

[COVID-19 Triage: Who is an inpatient? The Essen triage model]. / COVID-19-Triage: Wer bleibt stationär? Das Modell Essen.

INTRODUCTION: Data about optimal initial assessment in patients with suspicion for COVID19-infection or already confirmed infection are sparse. Especially, in preparation for expected mass casualty incident it is necessary to distinguish early and efficiently between outpatient and inpatient treatment including the need for intensive care therapy. METHODS: We present a model for a safe and efficient triage, which is established and used in the university hospital of Essen, Germany. It is intended for a non-disaster situation. This model is a combination of clinical assessment by using vital parameters and Manchester triage scale (MTS). Possible additional parameters are POCT (point-of-care-testing) values, electrocardiogram, CT pulmonary angiography, SARS-Cov2-PCR as well as detailed diagnostic of laboratory values. The model was validated by 100 consecutive patients. We demonstrate three patients to illustrate this model. RESULTS: During the first two weeks after implementing this model in our normal operation at the emergency department, we had an efficient selectivity between need for inpatient and outpatient treatment. 16 patients were classified as "inpatients" according to initial assessment. Among 84 patients who were initially classified as "outpatients", 7 patients returned to our emergency department within 14 days. Three of these patients returned due to complaints other than COVID19. One female patient had to be admitted due to progressive dyspnea. CONCLUSIONS: This introduced triage-model seems to be an efficient concept. Adjustment might be necessary after further experience and after a growing number of patients.