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Pseudo-safety in a cohort of patients with COVID-19 discharged home from the emergency department
  1. Neal Yuan1,
  2. Hongwei Ji2,3,
  3. Nancy Sun1,
  4. Patrick Botting1,
  5. Trevor Nguyen1,
  6. Sam Torbati4,
  7. Susan Cheng1,
  8. Joseph Ebinger1
  1. 1 Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
  2. 2 Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
  3. 3 Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
  4. 4 Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
  1. Correspondence to Dr Neal Yuan, Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; neal.yuan{at}


Introduction EDs are often the first line of contact with individuals infected with COVID-19 and play a key role in triage. However, there is currently little specific guidance for deciding when patients with COVID-19 require hospitalisation and when they may be safely observed as an outpatient.

Methods In this retrospective study, we characterised all patients with COVID-19 discharged home from EDs in our US multisite healthcare system from March 2020 to August 2020, focusing on individuals who returned within 2 weeks and required hospital admission. We restricted analyses to first-encounter data that do not depend on laboratory or imaging diagnostics in order to inform point-of-care assessments in resource-limited environments. Vitals and comorbidities were extracted from the electronic health record. We performed ordinal logistic regression analyses to identify predictors of inpatient admission, intensive care and intubation.

Results Of n=923 patients who were COVID-19 positive discharged from the ED, n=107 (11.6%) returned within 2 weeks and were admitted. In a multivariable-adjusted model including n=788 patients with complete risk factor information, history of hypertension increased odds of hospitalisation and severe illness by 1.92-fold (95% CI 1.07 to 3.41), diabetes by 2.20-fold (1.18 to 4.02), chronic lung disease by 2.21-fold (1.22 to 3.92) and fever by 2.89-fold (1.71 to 4.82). Having at least two of these risk factors increased the odds of future hospitalisation by 6.68-fold (3.54 to 12.70). Patients with hypertension, diabetes, chronic lung disease or fever had significantly longer hospital stays (median 5.92 days, 3.08–10.95 vs 3.21, 1.10–5.75, p<0.01) with numerically higher but not significantly different rates of intensive care unit admission (27.02% vs 14.30%, p=0.27) and intubation (12.16% vs 7.14%, p=0.71).

Discussion Patients infected with COVID-19 may appear clinically safe for home convalescence. However, those with hypertension, diabetes, chronic lung disease and fever may in fact be only ‘pseudo-safe’ and are most at risk for subsequent hospitalisation with more severe illness and longer hospital stays.

  • emergency care systems
  • admission avoidance
  • hospitalisations
  • infectious diseases
  • viral

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  • Handling editor Roland Merchant

  • Contributors NY, JE and SC conceived and designed the study. HJ, NS and PB performed data extraction and analysis. NY and JE wrote the manuscript with input from all authors.

  • Funding This research was supported by funding from NCI/NIAID U54 CA260591, NIH/NHLBI K23HL153888, Cedars-Sinai Medical Center and the Erika J. Glazer Family Foundation.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.