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Original article
Radiography-based triage for COVID-19 in the Emergency Department in a Spanish cohort of patients
Sistema de selección en urgencias de pacientes con sospecha de infección por SARS-CoV-2 y con posible neumonía no graves basado en la radiografía de tórax
Abiu Sempere-Gonzáleza, Jordi Llaneras-Artiguesa, Iago Pinal-Fernándezb,c,d, Esperanza Cañas-Ruanoa, Olimpia Orozco-Gálveza, Eva Domingo-Baldricha, Xabier Michelenaa, Beatriz Mezaa, Eloi García-Vivesa, Albert Gil-Vilaa, Javier Sarrapio-Lorenzoa, Sheila Romero-Rupertoa, Francesc Sanpedro-Jiméneza, María Arranz-Betegóna, Andreu Fernández-Codinaa,e,
Corresponding author
Andreu.fernandezcodina@wrh.on.ca

Corresponding author.
a Emergency Department, University Hospital Vall d’Hebron, Barcelona, Spain
b National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MA, USA
c Johns Hopkins University School of Medicine, Baltimore, MD, USA
d Faculty of Health Sciences and Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
e Rheumatology Division and General Internal Medicine Division-Windsor Campus, University of Western Ontario, London/Windsor, ON, Canada
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Flow chart for suspected COVID-19 triage at the ED&#46; ED<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Emergency Department&#44; MAT<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Model Andorr&#224; de Triatge</span> &#40;Andorran triage model&#41;&#44; PCR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>polymerase chain reaction&#46; All quantitative variables are shown as median &#40;standard deviation&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The disease associated with the 2019 coronavirus or COVID-19 was described after reports of patients with pneumonia associated with a new coronavirus &#40;SARS-CoV-2&#41; in Wuhan &#40;China&#41; in late 2019&#46; Currently&#44; COVID-19 is a global pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> The clinical presentation of COVID-19 is variable&#44; ranging from asymptomatic presentations to flu-like symptoms or adult respiratory distress syndrome &#40;ARDS&#41;&#46; Respiratory complications typically appear about 7&#8211;10 days after the first symptom&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> causing significant morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The spread of SARS-CoV-2 has caused significant peaks in healthcare demand&#46; Emergency Department &#40;ED&#41; triage during a pandemic is closer to that of an accident with multiple victims&#46; Furthermore&#44; no COVID-19 specific validated strategies have been developed&#44; despite different proposals exist&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> In early 2020&#44; the rapid increase of the number of cases was followed by a significant number of limitations&#58; diagnostic capacity &#40;less sensitive and slower polymerase chain reaction &#40;PCR&#41; tests&#44; no valid antigen tests&#41;&#44; clinical space&#44; human resources&#44; and personal protective equipment&#46; The preexisting experiences from China and Italy showed that chest X-ray &#40;CXR&#41; had a limited sensitivity to diagnose COVID-19 versus chest computerized tomography &#40;CT&#41;&#44; especially earlier in the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> The European Society of Radiology encouraged EDs to use CT&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Due to high patient volumes and congestion of our center in Barcelona&#44; Spain&#44; generalizing the use of chest CT was deemed as not feasible&#46; CXRs&#8217; sensitivity for COVID-19 is 69-75&#37; and it increases with a higher prevalence&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> Patients with severe manifestations&#44; especially respiratory insufficiency&#44; would obviously need admission to the hospital and high-level acute care at the ED&#46; We considered that CXR would be a fast and cheap way to stratify the different levels of severity upon ED triage in patients without apparent signs of severity on admission&#46; This way&#44; we would be able to safely discharge some of them home&#44; to concentrate our limited in-hospital resources on the right cases during the peak&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to report the outcomes of an ED triage system based on CXR for non-severe patients with suspected COVID-19 and possible pneumonia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Design and setting</span><p id="par0025" class="elsevierStylePara elsevierViewall">We performed a retrospective cohort study including patients visited at the Emergency Department &#40;ED&#41; at the Vall d&#8217;Hebron University Hospital &#40;Barcelona&#44; Spain&#41; from March 25 to April 8&#44; 2020&#46; This is a university tertiary care center&#44; with more than 1000 in-patient beds&#44; with an assigned population of more than 450&#44;000 people&#46; The period of inclusion included the 2 weeks when the hospital was at full capacity&#44; corresponding to the first incidence peak in the COVID-19 pandemic in Catalonia &#40;Spain&#41;&#46; For the 7-day period March 30 to April 5&#44; 2020&#44; the 14-day cumulative incidence of COVID-19 cases in Catalonia was 267&#46;07 &#40;population as of January 1&#44; 2020&#44; was 7&#44;722&#44;203 inhabitants&#41;&#44; 8928 new cases were diagnosed with PCR&#44; and 2649 people died&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> On 31 March 2020&#44; the center reached the peak of COVID-19 activity&#44; accounting for 100 daily admissions&#44; 170 inpatients at the intensive care unit&#44; and more than 600 inpatients in conventional wards&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this context&#44; a protocol for COVID-19 triage and management had been implemented at the institution &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Most of the patients visited at the ED had suspected COVID-19 and a physically separated circuit was made for non-COVID-19 patients&#46; Patients reporting possible COVID-19 symptoms were identified at the entrance&#44; admitted to the ED&#44; and triaged by a registered nurse using the Andorran triage model &#40;MAT&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">11&#44;12</span></a> an adaptation from the Canadian Emergency Department Triage and Acuity Scale &#40;CTAS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> Patients scoring levels I to III were transferred to the acute care area &#40;more severe cases or deconditioned&#44; generally needing oxygen&#44; stretcher&#41;&#46; Patients in levels IV and V suspicious for pneumonia were directly sent for CXR &#40;posterior-anterior and lateral projections&#44; reported by a dedicated radiologist&#41; and moved to a separated waiting room&#46; If the CXR was negative for pneumonia they were taken back to an advanced triage office&#44; where a physician made a rapid assessment&#44; provided isolation recommendations and symptomatic treatment&#44; and discharged patients to the care of their general practitioner&#46; Due to the limited availability of PCR kits&#44; those patients had them&#44; depending on availability&#44; a few days after under primary care supervision&#46; Those patients with pneumonia or with more functional impairment or inability to isolate at home were assessed by an ED physician&#44; got bloodwork drawn and a therapeutic&#47;admission decision was taken&#46; This subgroup of patients had their PCR swab at the ED &#40;Allplex 2019-nCoV&#44; Seegene&#44; Seoul&#44; South Korea<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a>&#41;&#46; No antigen or serology tests were available&#44; and the turnover for the microbiology lab results was 8&#8211;12<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">Inclusion criteria were&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients &#8805;16 years-old visited at the ED from March 25 to April 8&#44; 2020&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Screening positive for suspected COVID-19 symptoms and pneumonia &#40;including usual symptoms i&#46;e&#46; fever&#44; cough&#44; myalgias&#44; dyspnea&#44; chest pain&#44; &#8230;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">MAT<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">11&#44;12</span></a> level IV or V&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#41; room air<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>95&#37;&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data collection and processing</span><p id="par0060" class="elsevierStylePara elsevierViewall">A search into the electronic medical record SAP&#174; was performed including the following items&#58; patients visited at the ED for medical pathologies &#40;non-surgical&#44; ortho&#44; gynecology or pediatric&#41;&#44; visits from March 25 to April 8&#44; 2020&#44; MAT levels IV or V&#44; diagnostic codes specific for coronavirus infection &#40;coronavirus&#44; non-specific coronavirus infection&#44; other coronaviruses that cause diseases elsewhere specified&#41; or any viral or respiratory infection&#46; We obtained 1046 clinical encounters&#46; All charts were reviewed to check that the COVID-19 working diagnosis was accurate&#44; information was available&#44; and patients with repeated consults were identified&#46; The review was performed from June 19 to August 20&#44; 2020&#46; An anonymized password-protected database was created along with an encrypted master list kept by AFC&#44; ASG&#44; JLA&#44; and IPF&#46; The research team reviewed the different charts including the ED visit and the data available in the EMR &#40;in-hospital care&#44; primary care&#41; including the evolution up to 14 days after the ED visit&#44; and recorded any death &#40;in-patient or outpatient&#41; in the following 6 weeks&#46; The demographic variables included&#58; sex&#44; age&#44; race&#44; smoker status&#44; Charlson comorbidity index score&#44; death&#44; and date of death&#46; For COVID-19 specific items&#44; we reviewed&#58; SARS-CoV-2 PCR status&#44; time since the first symptom&#44; reported symptoms &#40;headache&#44; nasal congestion&#44; dry cough&#44; expectoration&#44; fatigue&#44; dyspnea&#44; nausea or vomiting&#44; diarrhea&#44; myalgia&#44; anosmia&#44; dysgeusia&#44; fever&#44; or febricula&#41;&#44; vitals &#40;systolic blood pressure&#44; diastolic blood pressure&#44; heart rate&#44; respiratory rate&#44; temperature&#44; SpO<span class="elsevierStyleInf">2</span> room air&#41;&#44; triage chest X-ray status &#40;viral pneumonia or not&#41;&#44; re-consult at the ED or primary care&#44; and presence of complications &#40;pneumonia&#44; deep vein thrombosis&#44; pulmonary embolism&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">STATA 14&#46;1 software was used for the statistical analysis&#46; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered significant&#46; Dichotomous variables were expressed as absolute frequencies and percentages&#44; and continuous variables were reported as means and standard deviations&#46; Comparisons between groups were made using Chi-squared&#44; Fisher&#39;s exact tests&#44; or Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; as appropriate&#46; Logistic and linear regression were used to adjust comparisons for age&#44; gender&#44; and race&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethics</span><p id="par0070" class="elsevierStylePara elsevierViewall">The study design adhered to the declaration on Helsinki for ethical principles for medical research involving human subjects&#46; The local ethics review board reviewed and approved this protocol &#40;PR&#40;AG&#41;334&#47;2020&#41;&#46; Since it was a retrospective study using chart review&#44; the obtention of informed consent was waived&#46; This manuscript follows the STROBE recommendations for reporting observational studies&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">From 1046 consecutive clinical encounters at our institution&#39;s ED with MAT levels IV&#8211;V held from March 25 to April 8&#44; 2020&#44; we identified 834 patients with suspected non-severe COVID-19 pneumonia&#44; who met the inclusion criteria&#46; The demographics and COVID-19-related symptoms reported during the ED visit are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">All patients had their triage CXR&#46; The features and outcomes according to the presence or absence of radiological viral pneumonia are also presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Compared to those without radiological evidence of pneumonia&#44; patients with pneumonia were more likely to be male and older&#44; without racial clinically relevant differences&#46; In addition&#44; they reported fatigue&#44; dyspnea&#44; diarrhea&#44; myalgia&#44; dysgeusia&#44; and fever more frequently &#40;all adjusted <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Those presenting with pneumonia were statistically significantly more likely to be admitted to the hospital and mortality tended to be higher in this subgroup&#46; Patients reconsulting were earlier in the course of the disease the first time they came to the ED &#40;6&#46;5 days from the first symptom vs&#46; 8&#46;6 in those who did not come back to the ED&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;009 multivariate analysis&#41;&#44; were more likely to have a normal baseline CXR in the initial ED visit &#40;62&#37; vs&#46; 32&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and experienced a lower number of deaths &#40;2 vs&#46; 9&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46; Deep vein thrombosis and pulmonary embolism within 14 days just appeared in 3 patients in the pneumonia subset&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Deceased patients were all white&#46; They had a median age of 80 years and a median Charlson index of 5&#46;4&#44; all statistically significantly different from the surviving cases&#46; Ten of them had pneumonia in their triage CXR and one did not&#46; She reconsulted 3 days after with a pathologic CXR&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">In the context of an abrupt surge of cases and with the need to optimize the use of resources&#44; we explored the use of CXR to screen non-critical patients with suspected COVID-19 pneumonia in the ED setting&#46; CXR was able to identify viral pneumonia in 60&#37; of 834 patients without respiratory insufficiency and MAT IV&#8211;V&#46; Those with a negative CXR were discharged home&#46; ED reconsults were limited in number&#44; although forty percent of them had new pneumonia in the control CXR&#46; Mortality was 0&#46;003&#37; among patients with negative CXR&#46; CXR for COVID-19 pneumonia screening in non-severe patients at the ED is an effective and feasible strategy to stratify those patients in need of hospital care and those who do not&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Barcelona was no exception for the COVID-19 pandemic&#46; The high volumes of patients posed a significant organizational challenge to provide the right level of care to each patient in a timely fashion&#46; Human resources&#44; space&#44; respiratory therapy equipment&#44; personal protective equipment&#44; and SARS-CoV-2 tests were scarce in our country&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> like in many others&#46; Patients with respiratory insufficiency and&#47;or pneumonia clearly need inpatient medical treatment to some degree and can be easily identified at the ED in the more severe triage groups &#40;MAT or CTAS I&#8211;III&#41;&#46; This subset of patients will consume a significant part of the ED capacity&#46; Therefore&#44; identifying patients who could be safely discharged is a priority&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The demographics of our series of patients corresponded to a subset of younger and less comorbid group of patients&#44; compared to all the patients who were visited at an ED<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a> or ended up being admitted due to COVID-19 in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> This is because our cases corresponded to mild COVID-19 disease&#44; without respiratory insufficiency or any other major organ damage as per MAT triage IV&#8211;V&#46; On presentation&#44; patients mainly reported cough&#44; fatigue&#44; myalgia&#44; and fever&#46; Dyspnea was only present in half of the patients&#44; whereas other reports mixing severe and non-severe patients found over 70&#37; of cases with shortness of breath&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> In terms of disease duration&#44; patients came to the ED about 8 days after the first symptom like in many other European series&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16&#44;18</span></a> Vitals on arrival are not comparable&#44; as we did not include more severe patients&#46; Some patients had fever&#44; but none had respiratory insufficiency or hemodynamical instability&#46; The lower number of positive PCR for the negative CXR subgroup can be explained due to the delayed performance of the swab in those patients that were discharged&#44; as the viral load gets lower over time&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We found that 60&#37; of the screened patients had viral pneumonia in the CXR&#46; CXR was initially discouraged for diagnosis of pneumonia in SARS-CoV-2 in low prevalence areas&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> In a context like ours&#44; it was found in a significant number of cases among patients without respiratory insufficiency&#46; CXR is cheap and can be done in any ED&#46; Other imaging approaches have proved effective in diagnosing COVID-19 pneumonia&#46; Using chest CT scans would include a dedicated machine and more time to do the image acquisition&#44; which is not feasible admitting 100 patients a day&#46; Lung ultrasound is another promising technique to diagnose COVID-19 pneumonia and to provide a prognosis in terms of respiratory deterioration in critical patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">20&#44;21</span></a> Quicker than CTs&#44; it is not available in all centers and needs personnel with ultrasound skills&#46; Our initial approach of dedicated radiologists reporting the tests has been recently refined&#46; A simple semiquantitative score has been created to stage the degree of involvement &#40;&#60;1&#47;3&#44; 1&#47;3 to 2&#47;3&#44; or &#62;2&#47;3 of lung parenchyma affected by alveolar opacities&#41;&#44; correlating with the risk of intubation after presentation at the ED&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> Artificial intelligence has been used to interpret retrospectively chest radiography&#44; being able to predict adverse outcomes in COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a> Nevertheless&#44; in a healthcare system at the brink of collapse&#44; any ED physician can interpret the CXR on its own&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Patients with suspected COVID-19 and possible pneumonia with a negative CXR screening were younger&#44; predominantly female&#44; with fewer comorbidities&#44; and experienced less mortality than those with pneumonia&#46; Once pneumonia was ruled out&#44; they were discharged home under primary care supervision&#46; This provided an important relief to the high volume of patients needing to remain at the hospital&#46; Forty percent of patients without previous pneumonia who reconsulted had a newly diagnosed pneumonia&#46; This is attributable to a lower number of days since the first symptom at the first ED visit&#46; Hence&#44; pneumonia might not be visible in the first CXR or simply had not developed already&#46; Only one old and frail patient with pneumonia in the second visit ended up dying&#46; One study in New York &#40;USA&#41; showed that 5&#46;6&#37; of COVID-19 patients reconsulted to the ED within 72<span class="elsevierStyleHsp" style=""></span>h after being discharged&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> CXR was not systematically done&#44; but 41&#37; of the reconsults needing admission had an abnormal CXR at the initial visit&#46; Moreover&#44; only 25&#37; of the admissions had a previously normal CXR&#46; Mortality was 16&#37;&#46; Another Spanish study on 925 COVID-19 discharges from the ED&#44; found a 20&#46;5&#37; of ED re-consultations&#44; mostly within patients with CTAS III&#46; Patients needing to be revisited differed from those who did not in having new CXR findings or not having a previous chest radiography&#44; an older age&#44; and comorbidities&#46; They suggested discharging any suspected COVID-19 patient under 48 years old without comorbidities and with normal vitals&#46; Finally&#44; a severity score for the need for high flow oxygen &#40;and therefore a worse prognosis&#41; was recently developed in our center with COVID-19 patients admitted to the Internal Medicine ward&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> Seventy percent of the patients did not need oxygen on admission&#46; The main predictors for that outcome were&#58; SpO<span class="elsevierStyleInf">2</span>&#47;fraction of inspired oxygen &#40;adjusted Hazard Ratio-aHR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#44; CXR &#40;aHR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; prior immunosuppressive therapy &#40;aHR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#41;&#44; obesity &#40;aHR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; interleukin-6 serum levels &#40;aHR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41; and platelet count &#40;aHR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;5&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">This study is limited by its retrospective and single-center design&#46; The triage algorithm might be difficult to export to other centers with different characteristics and epidemiological situations&#46; Moreover&#44; variables were obtained from medical reports performed under a unique situation of work overload and stress&#44; with some missing or underreported data&#46; There was no control arm as this was how the clinical protocol established at our center worked&#46; Otherwise&#44; the sample is big&#44; and data comes from an expert referral center for COVID-19&#46; A high incidence of COVID-19 is still making struggle many developing countries after repeated waves&#46; This feasible proposal could certainly help to optimize resource use in those situations&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Overall&#44; CXR is inexpensive&#44; convenient in the ED&#44; and strongly correlated with prognostic implications in COVID-19&#46; Choosing which patients will benefit from more intensive observation and treatment in-hospital is an unmet need&#46; Using the CXR triage model for patients with non-severe COVID-19 suspected pneumonia would help to identify those patients with early pneumonia and those without it who could be potentially discharged with a low complication rate&#46; Other techniques like lung ultrasound could be used for the same purpose&#46; Additionally&#44; strategies like home hospitalization for selected patients can be considered to decongest the ED and wards&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusion</span><p id="par0130" class="elsevierStylePara elsevierViewall">In summary&#44; CXR identified pneumonia in 60&#37; of a series of symptomatic non-severe suspected COVID-19 patients without respiratory insufficiency presenting at the ED with possible pneumonia&#46; Patients without radiological condensation had less mortality and were mostly discharged&#46; Deceased patients were elder and with a higher Charlson index&#46; The re-consultation rate was low compared to other series&#44; developing pneumonia in 40&#37; of bounce backs without previous pneumonia&#46; CXR triage for suspected COVID-19 pneumonia in patients with CTAS&#47;MAT IV&#8211;V in the ED could be useful to decongest urgent care facilities working at capacity during the pandemic&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Strategies to determine who could be safely discharged home from the Emergency Department &#40;ED&#41; in COVID-19 are needed to decongestion healthcare systems&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the outcomes of an ED triage system for non-severe patients with suspected COVID-19 and possible pneumonia based on chest X-ray &#40;CXR&#41; upon admission&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Retrospective&#44; single-center study performed in Barcelona &#40;Spain&#41; during the COVID-19 peak in March&#8211;April 2020&#46; Patients with COVID-19 symptoms and potential pneumonia&#44; without respiratory insufficiency&#44; with priority class IV&#8211;V &#40;Andorran triage model&#41; had a CXR upon admission&#46; This approach tried to optimize resource use and to facilitate discharges&#46; The results after adopting this organizational approach are reported&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We included 834 patients&#44; 53&#37; were female&#46; Most patients were white &#40;66&#37;&#41; or Hispanic &#40;27&#37;&#41;&#46; CXR showed pneumonia in 523 &#40;62&#46;7&#37;&#41;&#46; Compared to those without pneumonia&#44; patients with pneumonia were older &#40;55 vs 46&#46;6 years old&#41; and had a higher Charlson comorbidity index &#40;1&#46;9 vs 1&#46;3&#41;&#46; Patients with pneumonia were at a higher risk for a combined outcome of admission and&#47;or death &#40;91 vs 12&#37;&#41;&#46; Death rates tended to be numerically higher in the pneumonia group &#40;10 vs 1&#41;&#46; Among patients without pneumonia in the initial CXR&#44; 10&#37; reconsulted &#40;40&#37; of them with new pneumonia&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CXR identified pneumonia in a significant number of patients&#46; Those without pneumonia were mostly discharged&#46; Mortality among patients with an initially negative CXR was low&#46; CXR triage for pneumonia in non-severe COVID-19 patients in the ED can be an effective strategy to optimize resource use&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La pandemia de COVID-19 conlleva una alta ocupaci&#243;n de los servicios de urgencias &#40;SU&#41;&#46; Se requieren nuevas estrategias para optimizar la gesti&#243;n de estos recursos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir los resultados de un sistema de triaje en urgencias para pacientes no graves con sospecha de COVID-19 y posible neumon&#237;a&#44; basado en la radiograf&#237;a de t&#243;rax &#40;RT&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo&#44; unic&#233;ntrico realizado en Barcelona &#40;Espa&#241;a&#41; entre marzo y abril de 2020&#46; Se realiz&#243; una RT al ingreso en SU de pacientes con s&#237;ntomas de COVID-19 y sospecha de neumon&#237;a&#44; sin insuficiencia respiratoria&#44; con una prioridad clase IV-V &#40;sistema andorrano de triaje&#41;&#46; Esta medida pretende optimizar los recursos y facilitar las altas&#46; Se reportan los resultados tras adoptar esta estrategia&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 834 pacientes &#40;53&#37; mujeres&#44; 66&#37; cauc&#225;sicos&#44; 27&#37; hisp&#225;nicos&#41;&#46; La RT mostr&#243; neumon&#237;a en 523 &#40;62&#44;7&#37;&#41;&#46; Comparados con los pacientes sin neumon&#237;a&#44; los que s&#237; la padec&#237;an eran mayores &#40;55 vs&#46; 46&#44;6 a&#241;os&#41;&#44; con un &#237;ndice de comorbilidad de Charlson m&#225;s elevado &#40;1&#44;9 vs&#46; 1&#44;3&#41; y con mayor riesgo de ingreso y&#47;o muerte &#40;91 vs&#46; 12&#37;&#41;&#46; La mortalidad fue num&#233;ricamente mayor en el grupo con neumon&#237;a &#40;10 vs&#46; 1&#41;&#46; El 10&#37; de los pacientes sin neumon&#237;a en RT consultaron de nuevo al SU &#40;40&#37; con neumon&#237;a&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusi&#243;n</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La RT identific&#243; neumon&#237;a en m&#250;ltiples pacientes&#46; Los que no ten&#237;an neumon&#237;a fueron mayoritariamente dados de alta&#46; La mortalidad entre pacientes con RT negativa fue baja&#46; La RT como triaje para neumon&#237;a en pacientes con COVID-19 no grave puede ahorrar recursos&#46;</p></span>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Flow chart for suspected COVID-19 triage at the ED&#46; ED<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Emergency Department&#44; MAT<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Model Andorr&#224; de Triatge</span> &#40;Andorran triage model&#41;&#44; PCR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>polymerase chain reaction&#46; All quantitative variables are shown as median &#40;standard deviation&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>absolute number&#44; SBP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>systolic blood pressure&#44; DBP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>diastolic blood pressure&#44; HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>heart rate&#44; RR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>respiratory rate&#44; SpO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>oxygen saturation&#44; CXR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>chest X-ray&#44; PCR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>polymerase chain reaction&#44; ED<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Emergency Department&#46; Dichotomous variables were expressed as absolute frequencies and percentages&#44; and continuous variables as means and standard deviations&#46; Univariate bivariate comparisons for continuous variables used the Student&#39;s <span class="elsevierStyleItalic">t</span>-test and for dichotomous variables the Fisher&#39;s or Chi-squared tests&#44; as appropriate&#46; Multivariate comparisons used logistic and linear regression to adjust for age&#44; gender&#44; and race&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Days since first symptom</span>&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0145" class="elsevierStylePara elsevierViewall">Authors would like to acknowledge the collaboration and hard work in difficult times of rest of the Vall d&#8217;Hebron medical emergency group &#40;Santiago Aranda-Rodr&#237;guez&#44; Pablo Rodr&#237;guez De Vera-Mar&#237;n&#44; Cristina Marcos-Fosch&#44; Bego&#241;a Santos-Garc&#237;a de Vicu&#241;a&#44; Llu&#237;s Jubany-Mari&#44; Claudia Casellas-Montagut&#44; Mireia L&#243;pez-Corbet&#243;&#44; Andr&#233;s Parra-Rojas&#44; Isidro Sanz-P&#233;rez&#44; Marcelo Alvarado-C&#225;rdenas&#44; Cristina P&#233;rez-Cameo&#44; Paula Suanzes-D&#237;ez&#44; Juan Espinosa-Pereiro&#44; Luisa Roade-Tato&#44; Pau Bosch-Nicolau&#44; Jordi Navarro-Mercad&#233;&#44; Judit Vidal-Gonz&#225;lez&#41;&#44; ED staff &#40;registered nurses&#44; nurses&#44; clerks&#41; and all the other healthcare providers who transiently joined the ED&#46;</p>"
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Article information
ISSN: 23870206
Original language: English
DOI:10.1016/j.medcle.2021.05.021
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