Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, originated in Wuhan, Hubei Province, China in late 2019 and grew rapidly into a pandemic. As of the writing of this monograph, there are over 100 million confirmed cases worldwide and 2.3 million deaths.1 New York City, with over 630,000 COVID-19-positive patients and over 27,000 deaths, became the infection epicenter in the United States. The Mount Sinai Health System, with 8 hospitals spread across New York City and Long Island, has been on the forefront of the pandemic. This compendium summarizes the lessons learned through interdisciplinary collaborations to meet the varied challenges created by the explosive appearance of the infection in our community, and will be updated continuously as new research and best practices emerge. It is our hope is that the collaborations and lessons learned that went into creating these guidelines and protocols can serve as a useful template for other systems to adapt to their fight against COVID-19.
This monograph summarizes the evaluation, treatment, and disposition tactics the Mount Sinai Health System created and implemented to help manage a new disease that posed an unprecedented volume of critical patients and had no known treatment. While by no means all-encompassing, the methods outlined here are focused on the front-line emergency clinician. We provide a rubric of how to think about major decisions regarding workup, treatment, and disposition. There is a focus on providing fundamental care in a way that maximizes safety for both patients and clinicians. Discussions regarding personal protective equipment (PPE), operational flow, and nonmedical resources are beyond the scope of this monograph. Although not discussed in detail, many of the nodal points in clinical decision-making can likely be performed by both telemedicine and advanced practice providers.
Keywords: coronavirus disease 2019, COVID-19, SARS-CoV-2, patient flow, testing, PPE, Mount Sinai, protocols, testing, diagnostics, disposition, cardiac arrest, medication, monoclonal, intubation, asthma, dyspnea, death, smart phrase, discharge, proning, ARDS, shock, ventilator, return to work
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).
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.
Peter A. D. Steel, MA, MBBS
Brian Fengler, MD
Christopher R. Carpenter, MD, MSc
Stephen Cantrill, MD
Sandy Schneider, MD
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.
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.
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.
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).
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.
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.
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.
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).
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.
All current citations are listed on page 7 of the ACEP Emergency Department COVID-19 Management Tool.
Evan S. Leibner, MD, PhD; Sonya Stokes, MD, MPH; Danish Ahmad, MD; Eric Legome, MD
February 21, 2021