The Second Wave

I know you are hearing this phrase a lot lately. We are hearing all the time that, as things open up around our country and around that world, we may experience a second wave resurgence of new COVID-19 cases. But I’m not referring to a second wave of new COVID-19 patients. There is new research coming out regarding patients who had previously experienced COVID-19 being readmitted to the hospital for a second wave of symptoms. These people have gone home. They have been discharged. They have recovered to a functional point. And yet, here they come, back in to the Emergency Department showing symptoms of COVID all over again. Why? What is going on here?

My first thought when I read this article was, “Here we go as a healthcare system, sending people home too soon again, just like we have been pushed so hard to do.” I was making some assumptions based on what I already knew, but what was really going on? Turns out I wasn’t wrong. Those with shorter median length of ICU stay (less than 5 days) were more likely to return for care, however, they were also more likely to not require readmission. They just needed some extra support like NIV/NIPPV, medication, breathing treatments, etc, and then were discharged from emergency back to home. In addition to length of stay, there are some significant factors that can result in patients being at a higher risk of readmission after COVID-19 discharge. Let’s take a look at what those are so you can better inform your practice and keep a closer eye on these folks.

First off, WHY are these patients returning to the hospital after discharge? The most common reason is a resurgence in respiratory distress. Other reasons included chest pain, falls, soft tissue infections (We will talk more about this in an upcoming post), and altered mental status. Patients tended to return to the hospital within 4-5 days of discharge so this seems to be the high-risk time frame. There were also a few specific conditions and comorbidities that resulted in a higher risk of returning to the hospital after COVID-19.

Not surprisingly, patients who have a comorbidity of COPD had a higher risk of returning to the hospital after COVID-19 discharge (6.8% of returning patients). These patients already have a compromised respiratory system so incurring further damage from viral overload isn’t going to do them any favors. These patents are more likely to require advanced ventilatory support, are more likely to experience severe disease, and are more likely to have a negative overall outcome, so returning to the hospital is not unexpected.

What was a bit surprising is that patients with hypertension were even more likely to return to the hospital than patients with COPD (36% of returning patients)! The mechanism for this continues to remain unknown. However, if you consider the effects of COVID-19 on the circulatory system that we discussed in my post on DVTs, we can infer that the heart and vasculature are struggling for a number of reasons. Down this line of thinking, another factor that placed patients at a higher risk for readmission was whether or not they received anticoagulation therapy… Hmmmmm…

Lower BMI at hospital discharge was also associated with higher risk of return to the hospital. It was assumed in the article that the effects of frailty impacted the readmission rates. But, in addition to frailty, which is a defined system of events and presentations, I think we need to consider the effect significant muscle mass loss has on BMI. Because these patients are immobilized for a long period of time, they are more likely to lose significant amounts of muscle mass which then lowers their overall BMI (which is body mass in kg per cm of height). So, if you have a patient who has a large proportion of muscle mass at admission, and a low proportion of muscle mass on discharge, regardless of comorbidities or age, they may be at a higher risk of readmission.

Thankfully less than 4% of people who were discharged from the hospital after COVID-19 returned to the hospital. But for those 4%, more than half required readmission to the ICU, so if they do end up going back, they are probably in dire need of help.

For all of you out there treating patients who have returned home or to a sub-acute facility and are in that 5-ish day window after discharge, you need to be keeping an extra special eye on them if they have COPD, hypertension, low BMI, a shorter ICU stay, or did not receive anticoagulation therapy. Did I just name every home care patient? Maybe…

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Have any of your patients gone back to the ED after being discharged for COVID-19? Tell me about it in the comments!

References:

Somani, S., Richter, F., Fuster, V., De Freitas, J., Naik, N., Sigel, K., Boettinger, E. P., Levin, M. A., Fayad, Z., Just, A. C., Charney, A., Zhao, S., Glicksberg, B. S., Lala, A., Nadkarni, G. (2020). Characterization of Patients Who Return to Hospital Following Discharge from Hospitalization For COVID-19. MedRxiv [Pre-Print Release]. Retrieved from https://www.medrxiv.org/content/10.1101/2020.05.17.20104604v1.full.pdf+html

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