Given the potential for rapid decompensation, which rural COVID-19 patients with mild symptoms should be considered for early transport to larger centres? 

Posted on April 9, 2020 by Tomas Rapaport

Summary

There are no current guidelines that strictly dictate which patients should be transferred to larger care centers early in their disease course. It remains a clinical and judgement call on the part of the physician and the patient.   

I.   Government of Canada Recommendation (1)

  • According to the clinical management of patients with moderate to severe COVID-19 – Interim guidance by the Government of Canada, “patients with mild disease, including uncomplicated pneumonia, should be managed within the community, with appropriate precautions in place.” However; it also states that “a low threshold should be considered for medevac options, particularly for the elderly, persons with underlying medical conditions or persons with evidence of pneumonia, the latter point being somewhat contradictory. Lastly, it states that  “patients should be carefully monitored for signs of impending deterioration so that transfer can be arranged before intubation is required” without specifying if signs of impending deterioration are different in COVID19 patients versus other causes of deterioration
  • Relevant underlying medical conditions include, but are not limited to: lung disease, cancer, heart failure, cerebrovascular disease, renal disease, liver disease, DM, any immunocompromising condition, and pregnancy

II.   Possible severity markers to consider

  • In a large retrospective study of hospitalized patients in Wuhan, China, the median day of onset of sepsis was Day 9-10 after onset of symptoms (2)
  • This same study found that higher SOFA scores (a score of 4-5)  and a D-dimer greater than 1 microg/mL at admission were associated with higher mortality (2)
  • Severity of lymphopenia (< 20% at 10 days post symptom onset) may be associated with increased mortality in hospitalized patients (3)
  • Recent COVID19 discussions with Emergency and Critical Care specialists from the Greater Vancouver Area indicated that age, D dimer, and lymphopenia are the first things that they will look at as markers of severity (4)
  • As always, consideration should be given to the capabilities of your specific facility, as well as the patient’s frailty and social history: ability to return to care promptly if they should worsen, security of housing, degree of social support, etc (4)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Public Health Agency of Canada. Clinical Management of Patients with Moderate to Severe COVID-19 – Interim Guidance – Canada.ca [Internet]. Canada.ca. 2020 [cited 2020 Apr 9]. Available from: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/clinical-management-covid-19.html#8
  2. Tan L, Wang Q, Zhang D, Ding J, Huang Q, Tang Y-Q, et al. Lymphopenia predicts disease severity of COVID-19: a descriptive and predictive study. Signal Transduction and Targeted Therapy [Internet]. 2020 Mar 27 [cited 2020 Apr 10];5(1). Available from: https://www.nature.com/articles/s41392-020-0148-4 
  3. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet [Internet]. 2020 Mar [cited 2020 Apr 10];395(10229):1054–62. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
  4. UBC CPD COVID-19 UPDATE: ASK EMERGENCY AND CRITICAL CARE SPECIALISTS Webinar transcript [Internet]. 2020 [cited 2020 Apr 9]. Available from: https://ubccpd.ca/sites/ubccpd.ca/files/COVID-19-Webinar-Mar-26-Transcript.pdf

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.