Tool Helps Emergency Providers Better Stratify COVID-19 Patients
The American College of Emergency Physicians (ACEP) and Brentwood, TN-based EvidenceCare unveiled a severity classification tool designed to help frontline providers quickly determine what kind of care patients with COVID-19 will require. The tool is designed to help clinicians make appropriate evaluation and disposition decisions in accordance with expert guidance on the disease.1,2
Called the Emergency Department COVID-19 Severity Classification tool, the instrument consists of seven triage steps. It starts by assessing vital signs. Then, clinicians use patient’s nasal cannula flow rate, respiratory rate, and minimum documented pulse oximetry to calculate qCSI. Depending on this score, a patient is classified as mild-low risk, mild-at risk, severe, or critical.
Next, clinicians assess symptoms and note any risk factors. For example, a man older than age 60 years with one or more chronic medical problems puts him at serious risk for contracting COVID-19 and suffering major adverse outcomes.
By the final step, when the clinician considers discharge home criteria, it may be clear a patient can be released safely, which is one of the goals of the tool. “We wanted to create a tool that would help the emergency physician decide right off the bat if this is a person who can go home,” says Sandra Schneider, MD, FACEP, asssociate executive director for clinical affairs at ACEP. “One of the strengths of this tool is really the concentration on those patients who can go home. Many patients ... don’t need tests, they don’t need any fancy stuff; they can just go home with appropriate instructions and follow-up.”
By facilitating a quick decision on patients who can be discharged safely, EDs will save time and conserve resources. However, Schneider stresses such decisions will be backed up by solid evidence from experts who have been caring for patients with COVID-19 for some time now. Such experts weighed in with considerable input on the tool’s design.
“There is a group of patients we can just basically look at, do a few simple things ... and say they can go home,” Schneider says. “You don’t need a CBC [complete blood count], you don’t need bloodwork, and you don’t need a chest X-ray.”
For patients who do not meet the criteria to be discharged quickly, the clinician will move on to the next phase: step five (diagnostic testing) and step six (analyzing imaging and lab results) before moving on to step seven (disposition). The tool offers specific guidance on how to proceed, and delineates patients into different groups.
For instance, some patients may be placed in observation or sent home with telemedicine for several hours so clinicians can keep close tabs on them and respond quickly if their conditions worsen.
Another group of patients may require admission, but there is otherwise not much more care for the emergency clinician to provide while the patient remains in the ED.
“Then, there is the other end of the spectrum. Those are the patients who need critical care or will need critical care,” Schneider explains. “There are some hospitals, particularly smaller, rural hospitals, where this tool can be very helpful because it will [tell] them that a patient is going to need critical care.”
In such cases, the tool will prompt clinicians to find a facility that can provide appropriate critical care to the patient, and they can start making arrangements for transfer. “You can predict that these patients are going to require [that level of care] rather than waiting until they are so sick, and you are then emergently trying to get them out of the hospital.”
Finally, there will be a group of patients for whom it will be clear immediately they will require care in a facility that has advanced care resources, such as ventilators and extracorporeal membrane oxygenation.
Schneider observes the tool is particularly effective at illuminating which patients are at both ends of the severity spectrum, which can be helpful to emergency clinicians as they make their disposition decisions. Still, she stresses it is up to clinicians to consider the information provided, and then use their clinical judgment. “[The tool] gives you good guidance on whether or not a patient should go home, whether you have to keep a watch on them, or whether they actually need to be in the hospital or an ICU,” Schneider says.
Rely on Guidance
How effective is the tool? Schneider notes that in an ideal world, developers would create a tool, and then analyze its performance on a year’s worth of patients to see how it is performing before making it available to all providers. Sadly, the world is in the grips of a pandemic now. “This [tool] uses the best evidence we have. We have pretty good evidence right now that this tool works on both sides of the spectrum,” Schneider says, noting the tool performs well when it comes to identifying and sorting low-risk and high-risk patients.
Nevertheless, going forward, developers intend to monitor the tool and make any needed adaptations as any new therapies or protocols demonstrate better ways to differentiate and manage COVID-19 patients. Further, as the tool becomes integrated into EMR systems, Schneider notes it should be a relatively easy matter to release any changes or updates to all the providers who are using the tool. They will not have to wait and read about the changes in a journal article.
For the emergency clinician who already has seen 100 COVID-19 patients, the tool probably will not provide any fresh insight, Schneider acknowledges. “However, for the person who is seeing their first patient or their 10th patient, it is very helpful,” she says.
Further, Schneider notes the tool can provide reassurance to clinicians that they are doing the right thing for patients who present with this disease. “I encourage people to look at the tool, even if they are not going to use it for every patient ... just to make sure that the way they sort patients in the ED coincides with [the thinking] of the people who are the experts,” Schneider adds.
- American College of Emergency Physicians. Emergency Department COVID-19 Severity Classification.
- EvidenceCare. COVID-19 pathways.
The tool is particularly effective at illuminating which patients are at both ends of the severity spectrum, which can be helpful to emergency clinicians as they make their disposition decisions. Still, it is up to clinicians to consider the information provided, and then use their clinical judgment.
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