Pattern of Emergency Department referral during the COVID-19 outbreak in Italy.

BACKGROUND: The Coronavirus disease (COVID-19) outbreak is putting the European National Health Systems under pressure. Interestingly, Emergency Department (ED) referrals for other reasons than COVID-19 seem to have declined steeply. In the present paper, we aimed to verify how the COVID-19 outbreak changed ED referral pattern. METHODS: We retrospectively reviewed the clinical records of patients referred to the ED of a University Hospital in Northern Italy from 1 March to 13 April 2020. We compared the following data with those belonging to the same period in 2019: number of EDs accesses, rate of hospital admission, frequencies of the most common causes of ED referral, priority codes of access. RESULTS: The number of ED referrals during the COVID-19 outbreak was markedly reduced when compared to the same period in 2019 (3059 vs. 5691; -46.3%). Conversely, the rate of hospital admission raised from 16.9% to 35.4% (P<0.0001), with a shift toward higher priority codes of ED admission. In 2020, we observed both a reduction of the number of patients referred for both traumatic (513, 16.8% vs. 1544, 27.1%; χ2=118.7, P<0.0001) and non-traumatic (4147 vs. 2546) conditions. Among the latter, suspected COVID-19 accounted for 1101 (43.2%) accesses. CONCLUSIONS: The COVID-19 pandemic completely changed the pattern of ED referral in Italy, with a marked reduction of the accesses to the hospitals. This could be related to a limited exposure to traumas and to a common fear of being infected during EDs in-stay. This may limit the misuse of EDs for non-urgent conditions but may also delay proper referrals for urgent conditions.

Clinical stability and in-hospital mortality prediction in COVID-19 patients presenting to the Emergency Department.

BACKGROUND: The Novara-COVID score was developed to help the emergency physician to decide which Coronavirus disease (COVID) patient required hospitalization at Emergency Department (ED) presentation and to which intensity of care. We aimed at evaluating its prognostic role. METHODS: We retrospectively collected data of COVID patients admitted to our ED between March 16 and April 22, 2020. The Novara-COVID score was systematically applied to all COVID patients since its introduction in clinical practice and adopted to decide patients' destination. The ability of the Novara-COVID score to predict in-hospital clinical stability and in-hospital mortality were evaluated through multivariable logistic regression and cox regression hazard models, respectively. RESULTS: Among the 480 COVID patients admitted to the ED, 338 were hospitalized: the Novara-COVID score was 0-1 in 49.7%, 2 in 24.6%, 3 in 15.4% and 4-5 in 10.3% of patients. Novara-COVID score values of 3 and 4-5 were associated with lower clinical stability with adjusted odds ratios of 0.28 (0.13-0.59) and 0.03 (0.01-0.12), respectively. When in-hospital mortality was evaluated, a significant difference emerged between scores of 0-1 and 2 vs. 3 and 4-5. In particular, the death adjusted hazard ratio for Novara-COVID scores of 3 and 4-5 were 2.6 (1.4-4.8) and 8.4 (4.7-15.2), respectively. CONCLUSIONS: The Novara-COVID score reliably predicts in-hospital clinical instability and mortality of COVID patients at ED presentation. This tool allows the emergency physician to detect patients at higher risk of clinical deterioration, suggesting a more aggressive therapeutic management from the beginning.