MODE OF PRESENTATIONS AND OUTCOMES OF PATIENTS WITH

CORONAVIRUS DISEASE (COVID-19) AND THEIR CORRELATION TO ESI

IN THE EMERGENCY DEPARTMENT OF A TERTIARY CARE HOSPITAL
IN PAKISTAN

INTRODUCTION:
Coronavirus is one of the important viruses affecting human respiratory system. There are
two types of coronavirus (CoVs) that are identified as Severe Acute respiratory syndrome
(SARS-CoV) and Middle East respiratory syndrome (MERS-CoV). [1] These viruses belong
to a family called Coronaviridae. They are enveloped, non-segmented and have positive-
sense RNA. Usually this virus causes mild symptoms but the two types mentioned above
have caused huge number of deaths worldwide in past two decades. There are only few types
of this virus that have been identified so far. Recently, first case was reported in December
2019, from Wuhan, China which seemed to be a case of viral pneumonia but after
investigations turned out that the causative agent is novel corona virus-19. And since then,
several cases were reported from China and then multiple countries were involved. [2] Later,
the disease was named as COVID-19 and the virus as SARS-CoV-2 by World Health
Organization.
It affects lower respiratory tract and seems to cause Pneumonia. Patient usually presents with
fever, sore throat, dry cough and shortness of breath. There are other symptoms that had been
reported and those include fatigue, headache, diarrhea, hemoptysis and lymphopenia. The
incubation period of coronavirus is 5.2 days and after the period is over, symptoms starts to
appear. The median is of 14 days starting from the onset of symptoms till death and this
varies from person to person due to age and functional capacity of the immune system. [1] In
a large number of patients, the disease resolved spontaneously. But it showed serious and
fatal complications in other patients like severe pneumonia, multi organ failure, acute
respiratory tract syndrome, septic shock and death. [3] In a research, it was shown that till 22
January 2020, 571 cases were informed from 25 different provinces of China. On 25 January
2020, 1975 cases were reported and confirmed including 56 total deaths. Worldwide, the
confirmed number of cases on 16 February 2020 were 51,857 in 25 different countries. [1]
On 11 March, 2020 World Health Organization Declared COVID-19 a global pandemic. [4]
The diagnosis made by taking throat swab samples using virus nucleic acid technique kits. [5]
The spread of this disease was thought to be zoonotic in origin but it is now clear that
progression of spread is occurring through human-to-human transmission. [6] It was found
that older people with comorbid were at higher risk and suffered from severe form of the
disease due to the weakened immune functions. [7] Other risk factors beside advanced age
include chronic illness, immunocompromised and malignancy. [9]

The Emergency Committee of WHO proposed that the spread of this disease can be slowed
down by detection of the virus in early phase, isolating the patient, treating promptly and
tracing the contacts. The goal is to minimize the spread and prevention from complications.
[3]
In this study, we will describe the mode of presentation, discharge disposition and detailed
outcomes of the patients presenting to Emergency Department of Shifa International
Hospital, Islamabad, Pakistan and correlate it with initial assessment in the ER based on ESI
(emergency severity index). We will see how many of the patients were discharged and
hospitalized, whether the admitted patients were in normal wards or intensive care units, the
number of the patients intubated and the survival of the patients being hospitalized.

MATERIAL AND METHODS:

We reviewed clinical records, vital sets, laboratory and radiological results of the patients
using Electronic Medical Record (EMR). We obtained demographic, clinical, laboratory,
radiological and outcome data and jot down the information into data collection performas
(prepared by ourselves specifically for this study).
All COVID-19 RT-PCR confirmed cases who presented to Emergency Department of Shifa
International Hospital, Islamabad in Pakistan from April 2020 to July 2020 were included in
this study. Those who tested negative for COVID-19 RT-PCR were excluded from the study.
COVID-19 was confirmed using real time reverse transcription-polymerase chain reaction
(RT-PCR). Data was collected on the following parameters: Medical Record (MR) number,
age, gender, clinical presentation (Fever, flu, cough, shortness of breath, anosmia, diarrhea or
distaste), comorbid conditions (diabetes mellitus, hypertension, any malignancy, respiratory
related, renal related, stroke or other conditions like rheumatoid arthritis etc.), Laboratory
results which includes Acute COVID panel (Ferritin, C-reactive protein, lactate
dehydrogenase or LDH and D-dimers), radiological results (Chest XRay or High resolution
computed tomography also called as HRCT), Initial set of vitals on presenting to Emergency
Department which included Blood pressure, Pulse, Respiratory rate, Temperature and
Oxygen saturation, Discharge deposition from emergency department or admission to a
critical care or on a hospital floor and the outcome of the patient (discharged or a mortality
case).

STATISTICS:
Statistical analysis was done using SPSS software version 23. The collected data was
summarized as means (±SD; Standard Deviation) or medians Descriptive analysis were used
for demographics, clinical and laboratory data.

RESULTS:
A total of 959 patients presented to Emergency Department with suspicion of COVID-19 and
408 patients were included in this study with confirmed positive RT PCR COVID test. The
mean age was 56 (±14.77) years as described in Table 2. The patients consisted of 280
(68.6%) males and 128(31.4%) females as shown in Table 1. The most common symptoms
(table 3) at the time of presentation were Fever, cough and shortness of breath. Few patients
had diarrheal symptom too. Other symptoms included distaste, flu, anosmia
214 patients (52.5%), had chronic illnesses like cardiovascular and respiratory diseases,
cerebrovascular and renal system diseases, diabetes mellitus or malignant tumor conditions
while 194 patients (47.5%) were healthy and didn’t have any comorbid conditions. (Table 4)
Priority level were defined for 408 patients as per ESI triage scale; 7 patients were prioritized
at level 1 (P1), 107 patients at P2, 213 (maximum cases) were assigned P3, 18 were P4 and
14 were P5.
299 patients underwent radiological investigation (Chest X-ray or HRCT), which revealed
that 260 (63.7%) patients had Typical COVID-19 findings, 26(6.4%) had in-determined
findings while 13 (3.2%) had Atypical results (Table 5). 344 patients had laboratory
investigations done which included Acute COVID-19 panel, 325 had elevated C-reactive
protein levels, 231 had elevated LDH levels, 218 had elevated Ferritin levels and 112 had
elevated D-dimers levels (Table 6). At the time of presentation to Emergency Department,
initial set of vitals were recorded of these patients. The mean saturation of 344 patients of
oxygen was 90.9 (±12.07), mean value of pulse for 343 patients was 96 (±19.70), mean
systolic blood pressure for 347 patients was 126 (±19.49) while diastolic for 345 patients was
75 (±11.56). Respiratory rate was recorded of 338 patients and mean was 24 (±8.36) while
mean temperature of 332 patients was 37.3°C (±3.61) as described in Table 8.
Of 408 patients, 207 patients were discharged or transferred to other hospital due to non-
availability of bed and 179 were admitted. Out of 179, 47 patients needed critical care
admission and 124 were admitted to ward of the hospital (Table 7). At the end, it was found
that of 344 cases, 15 had expired while 327 patients survived. Among mortality cases, 5
patients expired in Emergency department, 8 patients in critical care unit while 2 patients
expired on floor.

DISCUSSION:
This is an extended descriptive study on the modes of presentations and outcomes of
Coronavirus (COVID-19) disease which includes data of 408 patients who presented to
Emergency Department of Shifa International Hospital in Islamabad, Pakistan. In this study,
we analysed mode of presentations, clinical outcomes and coorelation to ESI. SARS-CoV-2
belongs to the family of coronavirus. Corona virus has been named after its spikes which
resemble crown, present on its surface. It has been found to be associated with an animal
reservoir like bats. [10] It has been found through our analysis that more men are affected
then women. And it has been proved through various studies that males are affected more by
coronavirus disease as compared to women. [11]. Our study showed, those in older age
groups, males and with pre-existing chronic illness were at higher risk to have COVID-19
and this has been seen in few of the studies performed in various countries. [14] In this study
we found that through proper assessment and categorizing the patient an appropriate ESI
level, we can have a better outcome and low mortality ratio.
The term COVID-19 has applied to those patients who had confirm positive RT_PCR test
with or without radiological findings. In our study, majority of the patients presented with
typical symptoms of fever, cough, shortness of breath and diarrhea and it has been proved
through various researches that these are the common manifestations a person present with
who has been infected with CoV-SARS-2 [10,12] Our study showed different results of
radiological investigations. Out of 299cases, 260 had
Typical COVID-19 findings which implies ground-glass opacification seen in lungs
bilaterally, 26 had in-determined findings while 13 had Atypical results. Most of the patients
in our study, 325 patients out of 344 had elevated C-reactive protein levels, 231 patients had
elevated LDH levels, 218 were with increased ferritin levels and 218 had markedly elevated
D-dimers levels and this is in coherent with various studies being carried out. These
biomarkers along with initial set of vitals were helpful in assigning an appropriate triage level
to the patients [13].
The first set of vitals taken at the time of presentation of the patient to Emergency
Department were recorded and analysed in this study which revealed that coronavirus
infected patients doesn’t necessarily present with deranged vitals.

Our study reported a low case fatality rate which depicts only those patients who had definite
outcome (discharged or expired) and this can be due to different sample sizes.
We concluded that isolating the suspected cases early, reaching a final diagnosis and starting
early treatment can have better outcomes and the spread of the disease can be hindered.

LIMITATIONS:
Due to the design of our study and limitation to one tertiary care hospital, the results of our
 study can vary. There were some missing data due to incomplete documentation of history,
vitals and outcomes. Some cases had their tests done from outside laboratories and medical
history was scarce along with limited biomarkers were carried out. We didn’t include atypical
symptoms so those should be put into consideration

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