Practical Protocols for Managing Patients With SARS-CoV-2 Infection (COVID-19) in the Emergency Department

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ACEP ED COVID-19 Management Tool

• Introduction
• About the Score
• Calculator Review Author
• Evidence Appraisal
  • Step 1 - Severity Classification
  • Step 2 - Risk Prognostication
  • Step 3 - Risk Assessment
  • Step 4 - Diagnostic Testing
  • Step 5 - Diagnostic Interpretation
  • Step 6 - Disposition
  • Step 7a - Nonpharmacologic Treatment
  • Step 7b - Pharmacologic Treatment
• Instructions
• Calculator Creator
• References

Introduction

The ACEP ED COVID-19 Management Tool is an emergency department classification and management tool for adult patients (aged ≥18 years) with suspected or confirmed SARS-CoV-2 (v1.0, updated April 6, 2021).

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About the Score

The American College of Emergency Physicians (ACEP) Emergency Department COVID-19 Management Tool is intended to guide severity classification, risk stratification, and diagnostic and management decisions in adult patients (aged ≥18 years) with suspected or confirmed SARS-CoV-2 (COVID-19) infection in the emergency department.

There is no need to apply this tool to patients who are not being evaluated for COVID-19. If the patient is considered to have mild disease, this tool may help avoid further testing.

This algorithm is not intended to be a substitute for clinicians' clinical judgement. The algorithm is not exhaustive in regard to diagnostic and treatment recommendations for patients with COVID-19 and COVID-like illness. Presenting symptoms or conditions that may be manifestations of COVID-19 could also be manifestations of other serious disease (eg, myocardial infarction, pulmonary embolism, stroke), which may require additional specific diagnostic and therapeutic interventions not discussed in this tool.

Imaging, laboratory tests, treatment, and disposition should be considered based on disease severity and risk for disease progression. The United States Centers for Disease Control and Prevention (CDC) has more information on outcome risks associated with race, ethnicity, and access to health care resources. The American Journal of Obstetrics and Gynecology has published a guideline to assist with risk stratification of pregnant patients. The National Institutes of Health (NIH) maintains recommendations for appropriate diagnostic testing. Recommendations for respiratory support, intravenous fluids, and other interventions are also maintained by the NIH. Pharmacologic recommendations for patients with COVID-19 are evolving quickly; recommendations for pharmacologic management are maintained by the NIH and the Infectious Diseases Society of America.

Calculator Review Authors

Peter A. D. Steel, MA, MBBS

Brian Fengler, MD

Christopher R. Carpenter, MD, MSc

Stephen Cantrill, MD

Sandy Schneider, MD

Evidence Appraisal

Step 1 - Severity Classification

The disease severity classification categories utilized by this tool (mild, moderate, severe, critical) are based on the classification categories adopted by the NIH COVID-19 Treatment Guidelines Panel, which were developed based on an early consensus of the literature describing the disease entity initially pre-senting in Wuhan, China, and subsequently identified as SARS-CoV-2.

Step 2 - Risk Prognostication

This section utilizes the PRIEST COVID-19 clinical severity score as a validated tool to predict a patient’s risk for end organ failure and/or mortality. The PRIEST study was a mixed prospective and retrospective observational cohort study undertaken in 70 emergency departments across the United Kingdom. A total of 22,445 patients were included; all were suspected to have COVID-19 and presented between March 26, 2020 and May 28, 2020. This tool was included because it did not require diagnostic testing (ie, laboratory tests, imaging) as part of the evaluation of the patient.

Step 3 - Risk Assessment

In this section, the user is asked if the patient has any additional risk factors that could increase the risk of severe disease, organ failure, and/or mortality. The CDC maintains consistently updated data on the outcome risks associated with race/ethnicity, socioeconomic status, and access to health care resources. Additional references (Bellou et al 2020; Ebinger et al 2020; Lokken et al 2021; Strausz et al 2021; Williamson et al 2020; Tartof et al 2020) are provided to summarize evidence for other risk factors.

Step 4 - Diagnostic Testing

This section follows the NIH guidelines for testing recommendations. Recommendations within this section will be updated as the NIH updates its guidelines. Evidence for exertional O₂ measurement is included from additional references (Greenhalgh et al 2020; Goodacre et al 2020; Paglia et al 2020).

Step 5 - Diagnostic Interpretation

Laboratory values that have been associated with risk of disease progression, severe disease, and/or mortality are included in this section. Abnormal value cutoffs were heterogenous across the studies, so the working group determined the most pragmatic values to display within this summary tool. The following references were included: Bellou et al (2020), Guan et al (2021), Hahm et al (2021), and Payán-Pernía et al (2020). Clinicians are advised in this section to check with their own facility's laboratory to determine the abnormal cutoff values that are used there.

Step 6 - Disposition

This section presents an approach to disposition of the patient based on severity classification. Most of the section was developed by consensus among the working group. Supplemental evidence was included from Banerjee et al (2021), patient educational materials produced by the CDC, and resources for patients from JAMA.

Step 7a - Nonpharmacologic Treatment

This section cites 8 references that include recommendations for nonpharmacologic treatment of respiratory infections in general (eg, Patchett et al 2021), as well as for COVID-19 specifically (eg, Banerjee et al 2021). The recommendations are organized based on clinician assessment of disease severity. Some of the recommendations are consensus based.

Step 7b - Pharmacologic Treatment

This section is abstracted directly from the NIH COVID-19 treatment guidelines, the majority of which are evidence based. The entries are listed by severity of disease. When provided in the NIH guidelines, the strength of the recommendation and level of evidence for the recommendation are specified. (See Table 1 for definitions.) For example, the following recommendation is provided for moderate, severe, or critical COVID-19:

Remdesivir: For hospitalized patients who require minimal supplemental oxygen (BIIa).

Instructions

This tool is intended for use in patients aged ≥18 years. The evidence for management of COVID-19 is evolving quickly and recommendations may change.

Calculator Creator

• Stephen Cantrill, MD, FACEP
• Brian Fengler, MD
• Shannon Brown
• Christopher R. Carpenter, MD, MSc, FACEP, AGSF
• Brenna Farmer, MD, MBA, MS
• Kent C. Grimes
• Tara Khan, DO, MS
• Dan Mayer, MD
• Laura Melville, MD, MS
• David Ng, MD, MS, FACEP
• Christopher Sampson, MD, FACEP
• Sandy Schneider, MD, FACEP
• Saman Shahid, MBBS
• Bradley Shy, MD, FACEP
• Peter A. D. Steel, MA, MBBS
• Edward H. Suh, MD

References

All current citations are listed on page 7 of the ACEP Emergency Department COVID-19 Management Tool.

Original/Primary Reference

• American College of Emergency Physicians. Emergency department COVID-19 management tool. May 27, 2021. Accessed June 28, 2021.

Validation Reference

• COVID-19 Treatment Guidelines Panel Members. Coronavirus disease 2019 (COVID-19) treatment guidelines. National Institutes of Health. 2021. Accessed June 28, 2021.

Additional References

• American College of Emergency Physicians. COVID-19. Accessed June 28, 2021.
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• Banerjee J, Canamar CP, Voyageur C, et al. Mortality and readmission rates among patients with COVID-19 after discharge from acute care setting with supplemental oxygen. JAMA Netw Open. 2021;4(4):e213990. DOI: 10.1001/jamanetworkopen.2021.3990
• Bellou V, Tzoulaki I, van Smeden M, et al. Prognostic factors for adverse outcomes in patients with COVID-19: a field-wide systematic review and meta-analysis. Eur Respir J. 2021:2002964. DOI: 10.1183/13993003.02964-2020
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• Kameda T, Mizuma Y, Taniguchi H, et al. Point-of-care lung ultrasound for the assessment of pneumonia: a narrative review in the COVID-19 era. J Med Ultrason (2001). 2021;48(1):31-43. DOI: 10.1007/s10396-020-01074-y
• Lokken EM, Huebner EM, Taylor GG, et al. Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. Am J Obstet Gynecol. 2021;225(1):77.e1-77.e14. DOI: 10.1016/j.ajog.2020.12.1221
• Meira E Cruz M, Miyazawa M, Gozal D. Putative contributions of circadian clock and sleep in the context of SARS-CoV-2 infection. Eur Respir J. 2020;55(6):2001023. DOI: 10.1183/13993003.01023-2020
• Paglia S, Nattino G, Occhipinti F, et al. The quick walk test: a noninvasive test to assess the risk of mechanical ventilation during COVID-19 outbreaks. Acad Emerg Med. 2021;28(2):244-247. DOI: 10.1111/acem.14180
• Patchett D, Yang J, Northern J, et al. Viral respiratory infections: an ounce of prevention is worth a pound of cure. Mayo Clin Proc Innov Qual Outcomes. 2021;5(2):480-485. DOI: 10.1016/j.mayocpiqo.2020.12.008
• Payán-Pernía S, Gómez Pérez L, Remacha Sevilla ÁF, et al. Absolute lymphocytes, ferritin, C-reactive protein, and lactate dehydrogenase predict early invasive ventilation in patients with COVID-19. Lab Med. 2020;52(2):141-145. DOI: 10.1093/labmed/lmaa105
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• Sjoding MW, Dickson RP, Iwashyna TJ, et al. Racial bias in pulse oximetry measurement. N Engl J Med. 2020;383(25):2477-2478. DOI: 10.1056/NEJMc2029240
• Strausz S, Kiiskinen T, Broberg M, et al. Sleep apnoea is risk factor for severe COVID-19. BMJ Open Respir Res. 2021;8(1):e000845. DOI: 10.1136/bmjresp-2020-000845
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• Tartof SY, Qian L, Hong V, et al. Obesity and mortality among patients diagnosed with COVID-19: results from an integrated health care organization. Ann Intern Med. 2020;173(10):773- 781. DOI: 10.7326/M20-3742
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• United States Centers for Disease Control and Prevention. COVID-19 hospitalization and death by race/ethnicity. CDC. June 17, 2021. Accessed June 28, 2021.
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