LAUSR

Study Objective: Acute infection with COVID-19 is associated with a wide variety of symptoms and a range of clinical severity from benign to life-threatening. Certain ED presenting symptoms may be associated with either a severe or a benign outcome. The objective of this study was to evaluate the association of initial clinical symptoms with need for hospitalization, intensive care or death in ED patients within 30 days after presenting with acute symptomatic COVID-19. Methods: This study is a retrospective case-series of patients presenting to a single ED with acute symptomatic COVID-19 from March 7–August 9, 2020. Symptomatic patients with laboratory-confirmed SARS-CoV-2 infection were eligible for this study. Patients who tested positively for COVID-19 due to screening tests but had no reasonably associated symptoms were excluded. Structured chart review was performed, and participants were analyzed by three categories representative of clinical severity: intensive care unit (ICU) care/death, general ward admission, and ED discharge /convalescence at home. Outcomes were ascertained 30 days after initial presentation to account for escalation in severity after the ED visit. We conducted univariate and multivariable logistic regression analyses to report odds ratios and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) between hospital or ICU care/death versus convalescence at home and between ICU care/death versus general ward admission. Multivariable models were developed using stepwise selection in logistic regression. Results: In total, 994 patients were included in the study, of which, 551 (55.4%) patients convalesced at home, 314 (31.6%) patients required general ward admission, and 129 (13.0%) required ICU care or died. In the adjusted models, ED patients requiring hospital admission were more likely to be aged ≥ 65 years (aOR 7.4, 95% CI: 5.0, 10.8), Black/African American (aOR 3.0, 95% CI: 1.6, 5.8) or Asian/American Indian/Alaska Native/Other (aOR 2.2, 95% CI: 1.1, 4.3), and experience dyspnea (aOR 2.7, 95% CI: 2.0, 3.7) or diarrhea (aOR 1.6, 95% CI: 1.1, 2.2). However, they were less likely to experience sore throat (aOR 0.4, 95% CI: 0.2, 0.6), myalgia (aOR 0.5, 95% CI: 0.4, 0.7), headache (aOR 0.5, 95% CI: 0.4, 0.8), or olfactory/taste disturbance (aOR 0.5, 95% CI: 0.3, 0.8). ED patients who required ICU care or died were more likely to experience altered mental status (aOR 3.8, 95% CI: 2.1, 6.6), but were less likely to report history of fever (0.5, 95% CI: 0.3, 0.8). Conclusions: In ED patients with acute COVID-19, complaints of sore throat, myalgias, headache or smell/taste disturbances were associated with discharge and convalescence at home. Patients who were ≥ age 65, Black/African American, experiencing dyspnea, diarrhea, or altered mental status were more likely to undergo hospital admission. Among all admitted patients, altered mental status was positively associated with ICU care or death, and a history of fever was negatively associated with ICU care or death. COVID-19 presents with a heterogeneous constellation of symptoms, and an understanding of the association of the presenting symptoms with the ultimate patient outcome may be useful for allocating resources and targeting management plans. [Formula presented]