ACEP Emergency Department COVID-19 Management Tool

Abstract

This review examines the American College of Emergency Physicians' (ACEP) Emergency Department COVID-19 Management Tool (2021). The authors and contributors developed a tool to provide a framework to assist with severity classification, risk assessment, diagnostic workup, disposition, and treatment of patients with suspected or confirmed COVID-19 in the emergency department. By utilizing the tool from this study, the emergency nurse practitioner can confidently treat COVID-19 and reduce patient risks from unnecessary treatments or unneeded admissions.

MR. T, A 45-YEAR-OLD BLACK MAN, presents to the local emergency department (ED) with fever, cough, malaise, and a loss of taste and smell. He complains that the symptoms started 7 days ago and have been getting progressively worse. He lives with his wife and two young children. Two days ago, when the fever first started, he had a rapid COVID test performed at a neighborhood clinic that was negative. No one else at home has been sick. Mr. T works as a janitor at the local elementary school, which has been back in session for 2 weeks. This morning he lost his taste and smell and overall felt worse. Mr. T's medical history includes hypertension and diabetes type 2. He has no surgical history. He admits to having a beer or bourbon every night and denies smoking or recreational drug use. He works out twice a week at the gym with weights for 1 hr. Daily medications include hydrochlorothiazide, amlodipine, metformin, vitamin D, lisinopril, and a multivitamin. He has no medication allergies. A review of systems was positive for chills and fatigue but negative for chest pain, abdominal pain, nausea, vomiting, diarrhea, or headache. Mr. T has not received a COVID-19 vaccine at this time.

On examination, his vital signs include temperature 38.2 °C, heart rate 94, blood pressure 135/88 mmHg, O₂ saturation 95%, respiratory rate 22, and body mass index 27. He is well nourished, well hydrated, in no apparent distress, and is alert and oriented to person, place, time, and situation. His skin is warm and dry, without rash, sclera without icterus, and mucous membranes are moist. His tympanic membranes are pearly gray without injection or erythema. Nasal mucosa is boggy. His heart rate has a regular rate and rhythm without murmurs, gallops, or rubs. His lungs are clear without rales or wheezing. His abdomen is soft and nontender. His neurological examination reveals cranial nerves II–XII intact without focal deficits and normal gait. All other physical examination findings were within normal limits. Differential diagnoses for Mr. T. include COVID-19, pneumonia, upper respiratory infection, and less likely pulmonary embolus (PE), new-onset chronic obstructive pulmonary disorder.

A chest radiograph, electrocardiogram, complete blood cell count, troponin, magnesium, comprehensive metabolic panel, and rapid severe acute respiratory syndrome coronavirus 2 polymerase chain reaction (SARS-CoV-2 PCR) were ordered. These revealed no acute electrolyte abnormalities, anemia, leukocytosis, or infiltrates. The COVID PCR remains pending.

DISCUSSION OF NEW COVID-19 GUIDELINES FOR USE IN THE ED

The purpose of the American College of Emergency Physicians (ACEP, 2021) Emergency Department COVID-19 Management Tool is to aid ED clinicians with classification and management of the adult patient (older than 18 years) with suspected or confirmed COVID-19 (Cantrill & Fengler, 2021). The algorithm provides a practical framework for standardizing severity classification, risk assessment, diagnostic workup, disposition, and treatment.

According to Brian Fengler, MD (personal communication, July 27, 2021), during the early days of the COVID-19 pandemic an interagency, intraoperability work group was formed to synthesize and analyze the high volume of information being published from around the globe about COVID-19. This early group, which Dr. Fengler led, was diverse and included experts in informatics and from other organizations each having unique objectives and outcome goals. In early 2020, the ACEP requested that Drs. Fengler and Cantrill, who were working with the National Institutes of Health (NIH, 2021) on COVID recommendations, establish a team of emergency medicine researchers and leaders to create useable guidelines for the evaluation and management of patients with COVID-19 for use by emergency clinicians. During 2020, without much published data on treatment effectiveness, the ACEP work group published Version I of the COVID-19 management guidelines. Version I focused on classifying disease severity for risk stratification following NIH guidelines (B. Fengler, personal communication, July 27, 2021). Due to insufficient evidence of treatment efficacy, Version I did not include treatment recommendations (B. Fengler, personal communication, July 27, 2021). During 2020, the ACEP work group team formed three subgroups to each conduct literature searches and collate evidence in three topical areas—severity, diagnosis, and disposition/treatment. As new evidence regarding treatment continued during 2020 with evolving updates being published by the NIH, the ACEP work groups concluded in late 2020 that there was sufficient evidence established to retire Version I and publish Version II, the ACEP Emergency Department COVID-19 Management Tool, in January 2021 (B. Fengler, personal communication, July 27, 2021). Version II expanded Version I by including additional elements for risk stratification as well as diagnostic testing and treatment recommendations for patients of varying disease severity (B. Fengler, personal communication, July 27, 2021). Version II was developed to be consistent with NIH's guidelines to ensure that the Management Tool was based on scientifically derived evidence to guide treatment and disposition recommendations. The NIH guidelines have also formed the basis of treatment protocols developed by the Society for Critical Care Medicine (B. Fengler, personal communication, July 27, 2021). Consistency between ED and critical care patient management, based on the best evidence by the NIH, facilitates communication and treatment decision-making between emergency and critical care settings to optimize patient outcomes (B. Fengler, personal communication, July 27, 2021).

Since January 2021, the ACEP COVID-19 Management Tool has been updated three times to its current iteration based on rapidly changing NIH recommendations. A new update is anticipated in August 2021 (B. Fengler, personal communication, July 27, 2021).

The current Emergency Department COVID-19 Management Tool includes seven steps to systematically guide ED clinicians in assessing a patient's disease severity classification, risk prognostication, risk assessment, diagnostic testing, diagnostic interpretation, treatment, and disposition through a seven-step process (https://www.acep.org/corona/COVID-19-alert/covid-19-articles/covid-19-ED-management-tool-now-available/). Step 1 provides physical examination findings that classify COVID disease severity from mild, to moderate, severe, or critical. If during Step 1 the patient is classified as severe or critical, the clinician moves to Step 4—diagnostic testing. If the patient is classified as mild or moderate, the clinician is then prompted to assign a PRIEST score, a validated tool that contains additional variables that are associated with the risk of disease progression predictive of a patient's risk for end organ failure of mortality (Goodacre et al., 2021; Suh, Lang, & Zerihun, 2021).

PREIST score variables include vital signs, alertness, method of receiving oxygen, sex, age, and performance status (Cantrill & Fengler, 2021). Points are assigned based on these variables to yield a score and corresponding risk percentage. After calculating the predictive risk percentage, the clinician progresses to Step 3. Step 3 incorporates coexisting medical conditions that the Centers for Disease Control and Prevention (CDC) has determined are associated with a higher risk for progressing to severe COVID-19 disease (Centers of Disease Control and Prevention [CDC], 2021). According to the ACEP Management Tool if a patient is found to have one or more of the Step 3 additional risk factors the clinician is prompted to move to Step 4. Step 4 provides recommended diagnostic testing based on the risk stratification classification. Specifically, if a patient is classified as mild in Step 1, with a PRIEST score of less than 4 calculated in Step 2, having one or less risk factors from Step 3, the tool does not recommend any specific testing except exertional pulse oximetry assessment especially in patients who appear well (Cantrill & Fengler, 2021). Step 4 includes specific diagnostic tests that are recommended by the NIH for patients classified as moderate, severe, or critical. Examples of recommended diagnostic tests for patients in these disease severity categories include chest radiography, pulmonary ultrasound, electrocardiogram, complete blood count and differential, complete metabolic panel, and based on patient symptoms may also include computerized tomography (CT) of the chest, D-dimer, C-reactive protein, and ferritin levels (Cantrill & Fengler, 2021). Step 5 includes abnormal laboratory test ranges indicative of risk of disease progression, more severe disease, and/or mortality.

Step 6 provides detailed disposition parameters based on the patient's disease severity classification, PREIST score, risk for progression of disease, additional comorbid risk factors from Step 3, and diagnostic findings from Steps 4 and 5. Step 7 includes both pharmacologic and nonpharmacologic treatment considerations recommended by the NIH and the Infectious Diseases Society of America (IDSA; Cantrill & Fengler, 2021).

By utilizing the ACEP tool, emergency clinicians are able to systematically evaluate and manage patients based on their disease severity and risk factors using an evidence-based approach to optimize the diagnostic workup, therapeutic management, and disposition. Use of the tool improves the correct utilization of resources (Cho et al., 2020), which can be overwhelming as recommendations for care are continuously changing as the pandemic continues and new variants and disease characteristics arise.

Another aspect of the tool is suggested “smart phrases” that can be incorporated into electronic medical record (EMR) platforms to improve timely management and documentation. Smart phrases are blocks of text that the user can copy and paste into your hospital's EMR system to automatically create common ED presentations. Similarly, the ACEP partnered with MDCalc that has published a calculator based on the Management Tool criteria to assist in patient evaluation and management until EMR platforms incorporate recommended smart phrases (https://www.mdcalc.com/acep-ed-covid-19-management-tool).

AUTHOR COMMENTS

A cursory PubMed search using the search terms emergency department, COVID-19, and management yields more than 5,000 articles that have been published since 2020. This unprecedented amount of information can lead to confusion regarding how best to assess and manage a patient presenting with COVID-19 whether it is in the parking lot of an outpatient clinic or within the ED. While this Research to Practice article is not a typical research critique, given the state of the pandemic, I believe presenting a discussion of how this tool was developed and used can assist an emergency care clinicians in developing and following a systematic process to provide the best care for patients with COVID-19 to improve their outcomes and to optimize resource utilization.

In anticipation of subsequent high prevalence COVID waves, a dynamic tool that reliably predicts a patient's disease progression and potential outcomes, improves patient safety, offers ED provider confidence in treatment, and ED and hospital patient flow management is needed. The fact that the Management Tool is consistent with the NIH, IDSA guidelines and recommendations by the Society of Critical Care Medicine, communication between the ED and hospital units is facilitated, which can afford clinician job satisfaction as well as treatment efficiency and efficacy.

CONCLUSION/CASE REVISITED

Three hours after his initial assessment, the emergency nurse practitioner (ENP) returns to inform the patient that his PCR test is positive. Mr. T is feeling concerned as he feels that he has heard mixed messages about COVID-19 treatment, is worried about possibly being kept in the hospital since he feels well overall. While awaiting the return of his diagnostic studies, Mr. T. received supplemental oxygen at 2 liters via nasal cannula as recommended in the Management Tool based on his initial oxygen saturation of 95%. In applying the ACEP COVID-19 Management Tool guideline, the ENP determines that Mr. T is in the moderate risk category. In Step 1, his initial severity classification is in the mild category for his fever, cough, and loss of taste and smell and absence of shortness of breath, dyspnea, or an abnormal chest x-ray. However, his risk prognostication score in Step 2 gave him eight additional risk percentage points with four points for respiratory rate, one point for oxygen saturation level, one point for heart rate, one point for temperature, and one point for male sex. This indicates a 22% risk profile. In applying Step 3, Mr. T received additional consideration for his diabetes and hypertension, as these are considered part of the CDC's risk factors for COVID-19 outcomes (Rosenthal, Cao, Gundrum, Sianis, & Safo, 2020). Mr. T's workup to this point including a chest radiograph, electrocardiogram (EKG), complete blood count, and comprehensive metabolic panel is appropriate based on the tool guidelines. The ENP can consider at this time if a D-Dimer, pulmonary ultrasound, or CT of the chest are indicated. Because Mr. T is pulmonary embolism rule-out criteria (PERC) negative, a D-Dimer to rule out PE is not indicated at this time (Kline et al., 2008). Pulmonary ultrasound is not available at the ED and CT of the chest is not needed to guide care.

Based on Mr. T's presentation, normal laboratory tests, normal chest radiograph, and normal EKG, it is determined that these are not needed at this time as COVID-19 is the diagnosis. Guided by the ACEP Management Tool, the ENP reexamines and discusses treatment recommendations with Mr. T.

Mr. T's vital signs remain stable during his ED course. His fever has decreased to 38.0 °C after a dose of acetaminophen 650 mg while in the ED. The nurse walked Mr. T around the ED for 1 min and his oxygen saturation remained above 95% for the duration of the walk on the 2 liters of oxygen (O₂) via nasal cannula. His heart rate is 88, respiratory rate is 18, and his blood pressure 130/82 mmHg.

Although Mr. T does meet enough risk factors for admission to the hospital, through shared decision-making, the ENP and Mr. T determine that he can be safely discharged to home at this time based on the ACEP COVID-19 Management Tool (Cantrill & Fengler, 2021). After arranging for close follow-up with his primary care doctor, he was given strict return precautions, which included shortness of breath, dyspnea, ongoing fever, or low pulse ox readings at home. He was also given a prescription for home pulse oximeter as well as instructions for how to measure his oxygen saturation at home and what measurements would warrant a return to the ED. The ACEP COVID-19 Management Tool (Cantrill & Fengler, 2021) endorses that steroids and remdesivir are not recommended for Mr. T at this time based on his risk stratification. On discharge Mr. T is set up to receive monoclonal antibodies through a mobile integrated health service tomorrow, and he is agreeable to that plan.

A further complication in this case is that the local ED where the ENP is caring for Mr. T is experiencing reduced capacity due to increased volume of patients. Although Mr. T meets criteria for and requests that he be discharged to home, it should be noted that the ACEP tool addresses surge and capacity constraints that many hospitals experience. The Management Tool recommendation for surge and capacity constraints is to supply the patient with CDC educational materials, arrange a telehealth or in-person follow-up visit with the patient's primary care provider, and to consider home pulse oximetry and oxygen therapy.

CONCLUSION

COVID-19 management will remain an ongoing discussion in emergency medicine practice for the foreseeable future. Use of the ACEP COVID-19 Management Tool in the ED setting has major implications for guiding clinicians in navigating the rapidly changing recommendations and improving patient management and outcomes. The tool not only makes sure that patients get appropriate and safe care, but also reassures the ED clinician that they are adhering to evidence-based practice.