Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system

ObjectiveTo describe the characteristics and outcomes of patients with a clinical diagnosis of COVID-19 and false-negative SARS-CoV-2 reverse transcription-PCR (RT-PCR), and develop and internally validate a diagnostic risk score to predict risk of COVID-19 (including RT-PCR-negative COVID-19) among medical admissions.DesignRetrospective cohort study.SettingTwo hospitals within an acute NHS Trust in London, UK.ParticipantsAll patients admitted to medical wards between 2 March and 3 May 2020.OutcomesMain outcomes were diagnosis of COVID-19, SARS-CoV-2 RT-PCR results, sensitivity of SARS-CoV-2 RT-PCR and mortality during hospital admission. For the diagnostic risk score, we report discrimination, calibration and diagnostic accuracy of the model and simplified risk score and internal validation.Results4008 patients were admitted between 2 March and 3 May 2020. 1792 patients (44.8%) were diagnosed with COVID-19, of whom 1391 were SARS-CoV-2 RT-PCR positive and 283 had only negative RT-PCRs. Compared with a clinical reference standard, sensitivity of RT-PCR in hospital patients was 83.1% (95% CI 81.2%–84.8%). Broadly, patients with false-negative RT-PCR COVID-19 and those confirmed by positive PCR had similar demographic and clinical characteristics but lower risk of intensive care unit admission and lower in-hospital mortality (adjusted OR 0.41, 95% CI 0.27–0.61). A simple diagnostic risk score comprising of age, sex, ethnicity, cough, fever or shortness of breath, National Early Warning Score 2, C reactive protein and chest radiograph appearance had moderate discrimination (area under the receiver–operator curve 0.83, 95% CI 0.82 to 0.85), good calibration and was internally validated.ConclusionRT-PCR-negative COVID-19 is common and is associated with lower mortality despite similar presentation. Diagnostic risk scores could potentially help triage patients requiring admission but need external validation.

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“… 19 20 Few studies have assessed pragmatic tools to assess risk of COVID-19 based on readily available clinical or laboratory variables. 21 22 …”

Section: Discussionmentioning

confidence: 99%

False-negative RT-PCR for COVID-19 and a diagnostic risk score: a retrospective cohort study among patients admitted to hospital

et al. 2021

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“… 1 The winter peak of Covid-19 in England has seen the highest number of Covid-19 cases and hospital admissions to date, with over 3,000 admissions daily, and a peak of 34,015 inpatients with Covid-19. 1 Patient triage and cohorting are crucial to reducing nosocomial Covid-19, 3 but paucisymptomatic or pre-symptomatic cases limit clinical case detecting, 4 and screening with molecular diagnostics introduces delay. 5 We piloted the use of point of care antigenic testing for SARS-CoV-2 in patients admitted to hospital for rapid case detection in a period of high disease prevalence.…”

mentioning

confidence: 99%

“…Case identification is critical in reducing nosocomial transmission of SARS-CoV2. 3 While Ct values are not a direct measure of infectivity, they do correlate with RNA load and culture positivity and infectious dose. 6 , 7 Thus, LFD-positive patients, with higher viral loads, are most likely to represent those patients with the highest infectious risk in the healthcare environment.…”

mentioning

confidence: 99%

Use of lateral flow devices allows rapid triage of patients with SARS-CoV-2 on admission to hospital

Young

Eyre

Jeffery

2021

Journal of Infection

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“…A UK based study identi ed that 89% of nosocomial cases in their hospital had shared a room with a SARS-CoV-2 PCR positive individual. [18] Thus, priority for providing rapid/POC testing in UK at hospital admission should be for these hospitals with limited numbers of isolation rooms and limited access laboratory testing. Furthermore, since the use of the Yellow zones should be minimized, their number should change adaptively depending on COVID-19 prevalence, as well as prevalence of respiratory conditions and demand on theatres and other essential procedures.…”

Section: The Prioritization Of Rapid Testingmentioning

confidence: 99%

Care Pathway And Prioritization Of Rapid Testing For Covid-19 In UK Hospitals: A Qualitative Evaluation

Hicks

Winter

Green

et al. 2020

Preprint

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Objectives The second wave of the coronavirus pandemic is now established, occurring at a time of winter pressure on acute care in the NHS. This is likely to be more challenging then the first wave for the diagnosis of COVID-19 because of the similar symptomology with other respiratory conditions highly prevalent in winter. This study sought to understand the care pathways in place in UK NHS hospitals during the first wave (March-July 2020) for identification of patients with COVID-19 and to learn lessons to inform optimal testing strategies within the COVID-19 National Diagnostic Research and Evaluation Platform (CONDOR).Design, setting & participants Sixteen hospital-based clinicians from 12 UK NHS Trusts covering 10 different specialties were interviewed following a semi-structured topic guide. Data were coded soon after the interviews and analysed thematically.Results We developed a diagrammatic, high-level visualisation of the care pathway describing the main clinical decisions associated with the diagnosis and management of patients with suspected COVID-19. COVID-19 testing influenced infection control considerations more so than treatment decisions. Two main features of service provision influenced the patient management significantly: access to rapid laboratory testing and the number of single occupancy rooms. If time to return of result was greater than 24 hours, patients with a presumptive diagnosis would often be cohorted based on clinical suspicion alone. Undetected COVID-19 during this time could therefore lead to an increased risk of viral transmission.Conclusions During the winter months, priority for provision of rapid testing at admission should be given to hospitals with limited access to laboratory services and single room availability. Access to rapid testing is essential for urgent decisions related to emergency surgery, maternity services and organ transplant. The pathway and prioritization of need will inform the economic modelling, clinical evaluations, and implementation of new clinical tests in UK.

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Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system

Cited by 68 publications

References 18 publications

False-negative RT-PCR for COVID-19 and a diagnostic risk score: a retrospective cohort study among patients admitted to hospital

False-negative RT-PCR for COVID-19 and a diagnostic risk score: a retrospective cohort study among patients admitted to hospital

Use of lateral flow devices allows rapid triage of patients with SARS-CoV-2 on admission to hospital

Care Pathway And Prioritization Of Rapid Testing For Covid-19 In UK Hospitals: A Qualitative Evaluation

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