*Glenn Slick1
1Penn State College of Medicine, Hershey, PA
KEYWORDS: coronavirus, COVID-19, readmissions, telemedicine
Learning Objectives
1. Present a positive COVID-19 patient with multiple comorbidities who was readmitted hours after discharge
2. Question how assessment and documentation could affect care
3. Highlight how the indirect patient contact of telemedicine could influence exam evaluations
Case Description
A 40-year-old male with severe asthma and congestive heart failure presented to a tertiary care center Emergency Department (ED) after four days of worsening nonproductive cough and shortness of breath (SOB). The patient was seen one day prior at a neighboring community hospital for evaluation of symptoms suggesting viral infection and was referred to their outpatient COVID-19 testing site. Before being tested, his symptoms worsened and he presented to the ED.
Upon arrival, he was afebrile with an oxygen saturation of 99% on 11L aerosol face mask. He stated his symptoms were similar to asthma exacerbations that lead to intubations in the past. He denied chest pain, palpitations, and dizziness. His lungs showed diffuse wheezing with poor air movement. The patient tested positive for COVID-19, and radiographs showed left lower pneumonia with atypical features. He was then admitted to inpatient care. Nine days later, he desaturated to 87% during a telehealth guided Physical Therapy (PT) discharge evaluation. His oxygen saturation dropped during sitting-balance assessment and recovered within one minute of rest. The following day, he was discharged home based on his demonstration of mobile independence during PT and overall symptom improvements. Arriving home, the patient’s SOB worsened while climbing the stairs to his apartment, and an ambulance service brought him back to the hospital the same day. Upon arrival, the patient appeared SOB with an oxygen saturation of 99% on 4L nasal canula. The patient was admitted and was stable when discharged three days later.
Discussion
Here we reported a clinically symptomatic COVID-19 positive patient with a history of severe asthmatic exacerbations experiencing multiple readmissions during his clinical course. Disease novelty, resource allocations, inconsistent home access documentation, and telehealth limitations may have played roles in readmittance. In the patient’s initial ED evaluation, limited test access prolonged testing approval. A study describing COVID-19 screening from 1/20/2020 to 3/24/2020 noted continual reductions in testing restrictions and turnaround times as their COVID-19 laboratory infrastructure developed.1
During the discharge evaluation, PT determined the number of steps to his home entrance. However, a home suitability assessment questionnaire, forwarded to inpatient care, lacked questions regarding home access. In an investigation of hospital readmissions, interventions combining discharge planning and support reduced readmittance.2 Due to documentation discrepancies, alternative discharge plans were not considered that may have changed the patient’s course.
Additionally, PT evaluated the patient’s mobile independence while physically distancing themselves from direct patient contact. The inability to perform critical exam components (palpitation & touching) can be a significant limitation for clinicians.3 In addition to the inconsistent documentation across disciplines, this report observed how telemedicine evaluation protocols may also influence patient readmissions. Future research investigating discharge and diagnostic measures will be pivotal in shaping patient care beyond the current pandemic.
Author Information
Corresponding Author
* Glenn Slick, BS
gslick@pennstatehealth.psu.edu
Author Contributions
All author(s) have given approval to the final version of the manuscript.
Funding Sources
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Disclosures
No authors have any disclosures or conflicts of interest at this time.
Acknowledgements
None.
References
1. Miller, G. A., Buck, C. R., Kang, C. S., Aviles, J. M., Younggren, B. N., Osborn, S., & Keay, C. R. (2020). COVID‐19 in Seattle—Early lessons learned. Journal of the American College of Emergency Physicians Open, 1(2), 85-91.
2. Gucciardi, E., Cameron, J. I., Di Liao, C., Palmer, A., & Stewart, D. E. (2007). Program design features that can improve participation in health education inter-ventions. BMC medical research methodology, 7(1), 47.
3. Myers, D. R., Weiss, A., Rollins, M. R., & Lam, W. A. (2017). Towards remote assessment and screening of acute abdominal pain using only a smartphone with native accelerometers. Scientific reports, 7(1), 1-12.