Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis

• Published in: The American journal of emergency medicine 2022-04, Vol.54, p.274-278
• Main Authors: Bijur, Polly E., Friedman, Benjamin W., Baron, Sarah W., Ramasahayam, Abhiram, Nerenberg, Rebecca, Sharpe, Shellyann, Goldstein, D. Yitzchak, Esses, David
• Format: Article
• Language: English
• Subjects: Coronaviruses; Cough; COVID-19; COVID-19 - diagnosis; COVID-19 - epidemiology; COVID-19 testing; Diarrhea; Dyspnea; Emergency medical care; Emergency Service, Hospital; Fever; Headache; Humans; Nausea; Nose; Nosocomial infection; Nosocomial infections; Olfaction; Patients; Pharyngitis; Predictive value of tests; Respiration; Retrospective Studies; SARS-CoV-2; Sensitivity and specificity; Severe acute respiratory syndrome coronavirus 2; Vomiting
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2022.01.070

To determine how cohorting patients based on presenting complaints affects risk of nosocomial infection in crowded Emergency Departments (EDs) under conditions of high and low prevalence of COVID-19. This was a retrospective analysis of presenting complaints and PCR tests collected during the COVID-19 epidemic from 4 EDs from a large hospital system in Bronx County, NY, from May 1, 2020 to April 30, 2021. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for a symptom screen based on the CDC list of COVID-19 symptoms: fever/chills, shortness of breath/dyspnea, cough, muscle or body ache, fatigue, headache, loss of taste or smell, sore throat, nasal congestion/runny nose, nausea, vomiting, and diarrhea. PPV was calculated for varying values of prevalence. There were 80,078 visits with PCR tests. The sensitivity of the symptom screen was 64.7% (95% CI: 63.6, 65.8), specificity 65.4% (65.1, 65.8). PPV was 16.8% (16.5, 17.0) and NPV was 94.5% (94.4, 94.7) when the observed prevalence of COVID-19 in the ED over the year was 9.7%. The PPV of fever/chills, cough, body and muscle aches and nasal congestion/runny nose were each approximately 25% across the year, while diarrhea, nausea, vomiting and headache were less predictive, (PPV 4.7%–9.6%) The combinations of fever/chills, cough, muscle/body aches, and shortness of breath had PPVs of 40–50%. The PPV of the screen varied from 3.7% (3.6, 3.8) at 2% prevalence of COVID-19 to 44.3% (44.0, 44.7) at 30% prevalence. The proportion of patients with a chief complaint of COVID-19 symptoms and confirmed COVID-19 infection was exceeded by the proportion without actual infection. This was true when prevalence in the ED was as high as 30%. Cohorting of patients based on the CDC's list of COVID-19 symptoms will expose many patients who do not have COVID-19 to risk of nosocomially acquired COVID-19. EDs should not use the CDC list of COVID-19 symptoms as the only strategy to minimize exposure.