Study Objectives
Many COVID-19 testing algorithms in the United States focus on the key symptoms (KS) of fever, cough and shortness of breath. We sought to understand the likelihood key symptoms would be the presenting chief complaint (CC) of a COVID+ patient.
Our objective was to understand the presenting CC of COVID positive patients with regards to KS versus similar symptoms (SS).
Methods
The study population included patients presenting to 19 EDs in the upper Midwest ranging from critical access sites to larger quaternary care hospitals from 2/1-5/4/2020. All facilities utilize a common electronic health record (Epic systems, Verona, Wisconsin) with structured data entry for CCs. Comparisons between the CCs for COVID- and COVID+ patients were performed using two-sided Chi-squared tests. KS are defined as the presence of shortness of breath, fever, or cough. SS are complaints similar to KS, such as flu-like symptoms, respiratory distress, or COVID-19 inquiries. All other complaints are categorized as Not Immediately KS.
Results
A total of 7682 patients presented to the ED during the study time frame. Out of these patients, 166 (2.16%) tested positive for COVID-19. Overall, COVID+ patients were significantly more likely to present with the KS compared to COVID- patients (COVID+: 68.7%, COVID-: 54.0%, p < .001), as well as symptoms similar to these KS (COVID+: 7.8%, COVID-: 2.5%, p < .001). A patient presenting with KS/similar symptoms tests positive for COVID are 2.5 times higher than the odds that a patient without these symptoms tests positive (OR = 2.50, 95% CI: 1.74 - 3.59, p < .001). Table 1 provides a summary of the COVID+ cohort grouped by CC. COVID+ women tend to present more frequently without KS. Furthermore, 41-50 year old COVID+ patients most frequently report CC similar symptoms.
Conclusion
Patients presenting with KS are much more likely to test positive for COVID-19 than patients without KS, which is congruent with recommendations for testing in most algorithms. However, 23.5% of patients testing positive for COVID-19 had non-KS as the CC; in particular, patients in their 40s tended to present with non-KS CCs. Conservative algorithms must understand the variety of CC presentations associated with COVID-19 infection, as missed diagnosis will pose exposure risk to staff and other community members. Future research focused on the likelihood of patients having COVID-19 who present without a CC of fever, cough, or shortness of breath is recommended. This has the potential to further refine testing algorithms, preserve limited resources, and minimize potential exposure.
Table 1.
Cohort Characteristics (COVID+ Patients)
| Key Symptoms (N=114) | Similar Symptoms (N=13) | Not Immediately KS (N=39) | P-Value | |
|---|---|---|---|---|
| Age- Median [IQR] | 56 [36-68] | 47 [39-49] | 56 [30-70] | 0.98 |
| Age Group- n (%) | ||||
| 18 or Younger | 3 (3%) | 0 (0%) | 3 (8%) | 0.28 |
| 19-30 | 20 (18%) | 2 (15%) | 7 (18%) | >0.99 |
| 31-40 | 13 (11%) | 2 (15%) | 4 (10%) | 0.85 |
| 41-50 | 15 (13%) | 6 (46%) | 4 (10%) | 0.012 |
| 51-60 | 19 (17%) | 0 (0%) | 6 (15%) | 0.37 |
| Older than 60 | 44 (39%) | 3 (23%) | 15 (39%) | 0.59 |
| Sex- n (%) | ||||
| Male | 64 (56%) | 8 (62%) | 13 (33%) | 0.037 |
Note: P-values generated from ANOVA (age) and Fisher’s Exact tests