COVID-19 hospital admission appropriateness analysis

5Team of work COVID-19 from the Hospital Universitario Ramón y Cajal : Jesús María Aranaz Andrés, Francisco Bolúmar Montrull, Cornelia Bischofberger Valdés , Marco Espinel Ruiz, Ángela Lourdes Rincón Carlavilla, Amaranta McGee Laso, Manuela Serrano Pareja, Paloma Moreno Núñez, Jorge de Vicente Guijarro, Marta González Touya, Moisés David Espejo Mambié, Diego San José Saras, José Porto Tomas, Ana García de la Santa Viñuela, Claudia Corraliza Medina, Natividad Flores Andújar, Alberto González Muñoz, Jessica Alía Herrero, Laura Viñambres Álvarez, Sara de la Hoz San Clemente, Mercedes García Haro, Juan Manuel Ramos López, Gerardo Gómez Montero, Gema Nieto Gómez, Pablo Roncero Ponte Lira, Helena Santiago Hernández


Introduction
Inconsistencies in clinical practice, coupled with uncertainty, are constants across all scenarios and throughout all time. In countries with better-developed healthcare models, overuse is far more problematic than underuse, hence the appearance of methods for assessing hospital inadequacy at the end of the 20th century [1]. During the COVID-19 pandemic, hospital admission criteria have been questioned based on the alleged inconsistency between hospitals [2,3]. Several studies put the proportion of inappropriate visits to hospital emergency services at between 20% and 80% of the total [4,5]. However, these studies date to the pre-SARS-CoV-2 pandemic period.

Purpose
This study was to compare hospital admission criteria applied to COVID-19 patients in the emergency department of the Ramón y Cajal University Hospital (HURyC) and their alignment with the AEP (Appropriateness Evaluation Protocol) and PSI (Pneumonia Severity Index).

Methodology
The HURyC is an extremely complex hospital with approximately 720 beds. Between 14 September and 5 October 2020, 501 patients diagnosed with SARS-CoV-2 were admitted to the hospital through the HURyC emergency department. We selected a random sample of 40 of these patients from a list of patients arranged in date order.
The first patient was selected from the admissions on 14 September, and subsequent patients were selected at fixed intervals of 12 patients to a total of 40 patients.
The hospital admission criteria established in the emergency department of Hospital Ramón y Cajal (Table 1), the AEP and PSI scales were used [6,7] to meet the study objectives.

Severe Pneumonia without Ards Criteria
Confirmed with chest X-ray or lung ultrasound (In the absence of CHF) CURB65 > 1 and/or SpO2 < 92% breathing ambient air No ARDS criteria

Severe Pneumonia with Ards Criteria
Confirmed with chest X-ray or lung ultrasound (In the absence of CHF) CURB65 > 1 and/or SpO2 < 92% breathing ambient air ARDS criteria

Sepsis or Organic Dysfunction
Change on SOFA scale > 2 points QUICK SOFA (qSOFA) with 2 of the following 3 variables may identify serious patients: Glasgow ≤ 13; SBP ≤ 100 mmHg; RR ≥ 22 rpm Organ failure can present with the following abnormalities: Acute confusional state (delirium); respiratory failure; reduction in volume of diuresis; tachycardia; coagulopathy; metabolic acidosis

Septic Shock
Low blood pressure that persists after volume resuscitation and requires vasopressors to maintain MAP ≥65 mmHg and lactate ≥ 2 mmol/L (18 mg/ dL) in the absence of hypovolemia.

Results
All patients admitted to the hospital through the emergency department were hospitalised correctly according to the AEP scale, and 65% were hospitalised according to the HURyC admission criteria. If we add the patients hospitalised according to the hospital admission criteria with a SCORE equal to or greater than III on the PSI scale, the percentage of patients increases to 82.5%. Of these, 9.09% were non-mild infections (non-pneumonias); 60.61% were severe cases of pneumonia without ARDS; 9.10% had sepsis, and 21.21% were cases with PSI equal to or greater than III. A total of 17.5% of the patients did not fulfil the hospital admission or PSI criteria, and all these patients had mild pneumonia.

Discussion and conclusions
There is a need for a consensus on the hospital criteria to be