ABSTRACT
OBJECTIVE: To assess ability of National Early Warning Score 2 (NEWS2), systemic inflammatory response syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA), and CRB-65 calculated at the time of intensive care unit (ICU) admission for predicting ICU mortality in patients of laboratory confirmed coronavirus disease 2019 (COVID-19) infection. METHODS: This prospective data analysis was based on chart reviews for laboratory confirmed COVID-19 patients admitted to ICUs over a 1-mo period. The NEWS2, CRB-65, qSOFA, and SIRS were calculated from the first recorded vital signs upon admission to ICU and assessed for predicting mortality. RESULTS: Total of 140 patients aged between 18 and 95 y were included in the analysis of whom majority were >60 y (47.8%), with evidence of pre-existing comorbidities (67.1%). The most common symptom at presentation was dyspnea (86.4%). Based upon the receiver operating characteristics area under the curve (AUC), the best discriminatory power to predict ICU mortality was for the CRB-65 (AUC: 0.720 [95% confidence interval [CI]: 0.630-0.811]) followed closely by NEWS2 (AUC: 0.712 [95% CI: 0.622-0.803]). Additionally, a multivariate Cox regression model showed Glasgow Coma Scale score at time of admission (P < 0.001; adjusted hazard ratio = 0.808 [95% CI: 0.715-0.911]) to be the only significant predictor of ICU mortality. CONCLUSIONS: CRB-65 and NEWS2 scores assessed at the time of ICU admission offer only a fair discriminatory value for predicting mortality. Further evaluation after adding laboratory markers such as C-reactive protein and D-dimer may yield a more useful prediction model. Much of the earlier data is from developed countries and uses scoring at time of hospital admission. This study was from a developing country, with the scores assessed at time of ICU admission, rather than the emergency department as with existing data from developed countries, for patients with moderate/severe COVID-19 disease. Because the scores showed some utility for predicting ICU mortality even when measured at time of ICU admission, their use in allocation of limited ICU resources in a developing country merits further research.
ABSTRACT
Aims/Objectives/Background Emergency Medical Service (EMS) and other practitioners assessing patients with suspected COVID-19 in the community must rapidly determine whether patients need treatment in hospital or can self-care. Tools to triage patient acuity have only been validated in hospital populations. We aimed to estimate the accuracy of five risk-stratification tools recommended to predict severe illness and compare accuracy to existing clinical decision-making in a pre-hospital setting. Methods/Design An observational cohort study using linked ambulance service data for patients assessed by EMS crews in the Yorkshire and Humber region of England between 18th March 2020 and 29th June 2020 was conducted to assess performance of the PRIEST tool, NEWS2, the WHO algorithm, CRB-65 and PMEWS in patients with suspected COVID-19 infection. The primary outcome was death or need for organ support. Results/Conclusions Of 7550 patients in our cohort, 17.6% (95% CI:16.8% to 18.5%) experienced the primary outcome. The NEWS2, PMEWS, PRIEST tool and WHO algorithm identified patients at risk of adverse outcomes with a high sensitivity (>0.95) and specificity ranging between 0.3 (NEWS2) and 0.41 (PRIEST tool). The high sensitivity of NEWS2 and PMEWS was achieved by using lower thresholds than previously recommended (NEWS2;0-1 vs 2+ and PMEWS;0-2 vs 3+). On index (first) assessment, 65% of patients were transported to hospital and EMS decision to transfer patients achieved a sensitivity of 0.84 (95% CI 0.83 to 0.85) and specificity of 0.39 (95% CI 0.39 to 0.40) to the primary outcome. This does not account for clinical reasons not to convey patients to hospital who subsequently deteriorated. Use of NEWS2, PMEWS, PRIEST tool and WHO algorithm could therefore potentially improve EMS triage of patients with suspected COVID-19 infection. Use of the PRIEST tool could significantly increase the sensitivity of triage without increasing the number of patients conveyed to hospital. (Table Presented).