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Performance of three screening tools to predict COVID-19 positivity in emergency department patients
  1. Madeline A DiLorenzo1,2,
  2. Megan R Davis3,
  3. Julianne N Dugas4,
  4. Kerrie P Nelson5,
  5. Natasha S Hochberg3,6,
  6. Robin R Ingalls3,6,
  7. Rebecca Grochow Mishuris2,
  8. Elissa M Schechter-Perkins4
  1. 1 Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
  2. 2 Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
  3. 3 Boston University School of Medicine, Boston, Massachusetts, USA
  4. 4 Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts, USA
  5. 5 Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
  6. 6 Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Madeline A DiLorenzo, Division of Infectious Diseases and Immunology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; madeline.dilorenzo{at}


Background COVID-19 symptoms vary widely. This retrospective study assessed which of three clinical screening tools—a nursing triage screen (NTS), an ED review of systems (ROS) performed by physicians and physician assistants and a standardised ED attending (ie, consultant) physician COVID-19 probability assessment (PA)—best identified patients with COVID-19 on a subsequent reverse transcription PCR (RT-PCR) confirmation.

Methods All patients admitted to Boston Medical Center from the ED between 27 April 2020 and 17 May 2020 were included. Sensitivity, specificity and positive predictive value (PPV) and negative predictive value (NPV) were calculated for each method. Logistic regression assessed each tool’s performance.

Results The attending physician PA had higher sensitivity (0.62, 95% CI 0.53 to 0.71) than the NTS (0.46, 95% CI 0.37 to 0.56) and higher specificity (0.76, 95% CI 0.72 to 0.80) than the NTS (0.71, 95% CI 0.66 to 0.75) and ED ROS (0.62, 95% CI 0.58 to 0.67). Categorisation as moderate or high probability on the ED physician PA was associated with the highest odds of having COVID-19 in regression analyses (adjusted OR=4.61, 95% CI 3.01 to 7.06). All methods had a low PPV (ranging from 0.26 for the ED ROS to 0.40 for the attending physician PA) and a similar NPV (0.84 for both the NTS and the ED ROS, and 0.89 for the attending physician PA).

Conclusion The ED attending PA had higher sensitivity and specificity than the other two methods, but none was accurate enough to replace a COVID-19 RT-PCR test in a clinical setting where transmission control is crucial. Therefore, we recommend universal COVID-19 testing prior to all admissions.

  • COVID-19
  • clinical assessment
  • diagnosis
  • infections

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No data are available.

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  • Handling editor Ellen J Weber

  • Twitter @madelinediloren

  • Contributors MAD, NSH, RRI, RGM and EMS-P designed the study. MAD, JND and EMS-P designed the data collection tools. MAD and JND monitored the data collection. MRD collected the data. JND and KPN wrote the statistical analysis plan and performed the statistical analysis. MAD, MRD and EMS-P drafted the paper. MAD and EMS-P are the guarantors for the study. All authors revised the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MAD owns stock in AbbVie, Agilent Technologies, Amgen, BioMarin Pharmaceuticals, Bristol Myers Squibb, Cardinal Health, CVS Health, Gilead Sciences, GlaxoSmithKline, Hologic, Jazz Pharmaceuticals, Labcorp, Merck & Co, Quest Diagnostics, Vertex Pharmaceuticals and West Pharmaceuticals. While all these companies are currently or may in the future do research related to COVID-19, none of these companies make products that were evaluated in this study.

  • 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.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.