Comparison of COVID-GRAM, 4C Mortality, qSOFA, SIRS, NEWS, and MEWS in Predicting Mortality in COVID-19

Objective: Mortality prediction methods are still controversial about coronavirus disease-2019 (COVID-19) pneumonia. This study aimed to compare the efficacy of the the quick Sequential Organ Failure Assessment, systemic inflammatory response syndrome (SIRS), Modified Early Warning score (MEWS), National Early Warning score, 4C mortality, and COVID-GRAM critical illness risk score (COVID-GRAM), scoring systems in predicting 28-day mortality in adult patients with COVID-19.Methods: This single-center, retrospective, observational cohort study included patients presenting to a pandemic hospital between November 2021 and December 2021. Inclusion criteria were patients aged 18 years or older, patients with positive reverse transcription-polymerase chain reaction test, and thoracic computed tomography imaging. The receiver operating characteristic analysis was performed to examine the diagnostic accuracy of the investigated scoring systems in predicting 28-day mortality. Statistical analyses were performed using the SPSS and MedCalc software packages. A p-value of <0.5 was considered statistically significant.Results: The study was conducted in 846 patients. The median age of the patients included in the study was 49 (36-75) years, and the rate of male patients was 46.3% (n=392). The rate of pneumonia detection was 85.1% (n=720). The hospitalization rate was 49.6% (n=420), the admission rate to the intensive care unit was 7.4% (n=63), and the 28-day mortality rate was 5.7% (n=48). The highest area under the curve (AUC) values for 28-day mortality prediction was obtained from COVID-GRAM (AUC: 0.935) and 4C mortality (AUC: 0.922) scores, while the lowest AUC values were calculated in SIRS (AUC: 0.756) and MEWS (AUC: 0.805).Conclusion: According to our results, COVID-GRAM may be the first-choice scoring system in the emergency department for predicting the 28-day mortality associated with COVID-19.

Early warning score versus quick sequential organ failure assessment in COVID-19 EWS vs qSOFA in COVID-19

Aim: COVID-19 is a viral pandemic that has affected the whole world in 2020. Our knowledge about this infection is improving each day. The emergency department (ED) management of COVID-19 patients is still unclear. Early warning scores (EWSs) and quick sequential organ failure assessment (qSOFA) are widely used scores in the ED. In this study, we aimed to compare EWSs and qSOFA scores in COVID-19 patients. Material(s) and Method(s): We evaluated patients diagnosed and hospitalized with COVID-19 between 10 April 2020 and 17 April 2020, including 63 COVID-19-positive patients. We calculated both EWSs and qSOFA scores for all patients and compared them by hospitalization unit (clinic or intensive care unit [ICU]), hospitalization length, and outcome. Result(s): EWS was positively correlated with hospitalization length, but we could not find a relationship between qSOFA and hospitalization length. The ICU hospitalization rate increases with high EWSs AND qSOFA scores. The mean EWS of patients hospitalized in the inpatient clinic was 1.39 and that of patients hospitalized in the ICU was 5.7. These scores were significantly different (p=0.000). The mean EWS of the patients who were discharged from the hospital was 1.6, and that of the exitus patients was 11.7 (p = 0.01). These values were 0.06 and 2.25 for qSOFA, respectively. Discussion(s): Both qSOFA and EWSs can predict the hospitalization unit and mortality, but EWSs are superior in determining the hospitalization length of COVID-19 patients.Copyright © 2022, Derman Medical Publishing. All rights reserved.

National Early Warning Score 2 (NEWS2) on admission predicts severe disease and in-hospital mortality from Covid-19 - a prospective cohort study.

BACKGROUND: There is a need for validated clinical risk scores to identify patients at risk of severe disease and to guide decision-making during the covid-19 pandemic. The National Early Warning Score 2 (NEWS2) is widely used in emergency medicine, but so far, no studies have evaluated its use in patients with covid-19. We aimed to study the performance of NEWS2 and compare commonly used clinical risk stratification tools at admission to predict risk of severe disease and in-hospital mortality in patients with covid-19. METHODS: This was a prospective cohort study in a public non-university general hospital in the Oslo area, Norway, including a cohort of all 66 patients hospitalised with confirmed SARS-CoV-2 infection from the start of the pandemic; 13 who died during hospital stay and 53 who were discharged alive. Data were collected consecutively from March 9th to April 27th 2020. The main outcome was the ability of the NEWS2 score and other clinical risk scores at emergency department admission to predict severe disease and in-hospital mortality in covid-19 patients. We calculated sensitivity and specificity with 95% confidence intervals (CIs) for NEWS2 scores ≥5 and ≥ 6, quick Sequential Organ Failure Assessment (qSOFA) score ≥ 2, ≥2 Systemic Inflammatory Response Syndrome (SIRS) criteria, and CRB-65 score ≥ 2. Areas under the curve (AUCs) for the clinical risk scores were compared using DeLong's test. RESULTS: In total, 66 patients (mean age 67.9 years) were included. Of these, 23% developed severe disease. In-hospital mortality was 20%. Tachypnoea, hypoxemia and confusion at admission were more common in patients developing severe disease. A NEWS2 score ≥ 6 at admission predicted severe disease with 80.0% sensitivity and 84.3% specificity (Area Under the Curve (AUC) 0.822, 95% CI 0.690-0.953). NEWS2 was superior to qSOFA score ≥ 2 (AUC 0.624, 95% CI 0.446-0.810, p < 0.05) and other clinical risk scores for this purpose. CONCLUSION: NEWS2 score at hospital admission predicted severe disease and in-hospital mortality, and was superior to other widely used clinical risk scores in patients with covid-19.

Clinical Profile of Patients Presenting With Sepsis to the Emergency Department of a Tertiary Care Hospital in Wardha During the COVID Pandemic (June 2020-June 2021).

Background Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock, multi-organ dysfunction, and death occur in severe cases with reduced blood flow to vital organs. Sepsis contributes to 15-20% of all global deaths. Through this study, we intend to evaluate the clinical profile and study the common blood investigatory panels along with organisms causing sepsis in patients presenting with sepsis in the emergency department during the COVID pandemic. In addition, the study was also done to estimate the prevalence of sepsis and compare patients having sepsis with serum lactate, sepsis with Systemic Inflammatory Response Syndrome (SIRS) criteria, and sepsis with quick Sepsis Related Organ Failure Assessment (qSOFA) score. Method Observational retrospective study to evaluate patients presenting with sepsis diagnosed by the Third International Consensus Definitions for Sepsis and Septic Shock" criteria presenting to the emergency department of Acharya Vinoba Bhave Rural Hospital (AVBRH) affiliated to Jawaharlal Nehru Medical College (JNMC), Wardha during COVID pandemic (June 2020-June 2021). Results The majority of the patients presented with fever (42%), and very few presented with altered mental status (8%). Seventy-four percent of the study population did not show any bacterial growth on blood culture, but out of the remaining 26%, blood culture, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pnemoniae were the significant microbes. Amongst qSOFA, SIRS criteria, and serum lactate as a screening tool for sepsis, SIRS is the most sensitive for screening sepsis patients. Conclusion Staphylococcus aureus, Pseudomonas aerugenosa, and Klebsiella pneumoniae were the major contributors in the development of sepsis in COVID-19-associated infection. The presence of raised leukocyte counts and serum lactate should alarm clinicians of possible sources of infection. The timely initiation, rapid de-escalation of empirical antibiotics, and strict compliance with infection control practices should be accomplished to reduce the occurrence of multidrug resistance organisms.

Brixia and qSOFA Scores, Coagulation Factors and Blood Values in Spring versus Autumn 2021 Infection in Pregnant Critical COVID-19 Patients: A Preliminary Study.

(1) Background: From the recent variants of concern of the SARS-CoV-2 virus, in which the delta variant generated more negative outcomes than the alpha, we hypothesized that lung involvement, clinical condition deterioration and blood alterations were also more severe in autumn infection, when the delta variant dominated (compared with spring infections, when the alpha variant dominated), in severely infected pregnant patients. (2) Methods: In a prospective study, all pregnant patients admitted to the ICU of the Elena Doamna Obstetrics and Gynecology Hospital with a critical form of COVID-19 infection-spring group (n = 11) and autumn group (n = 7)-between 1 January 2021 and 1 December 2021 were included. Brixia scores were calculated for every patient: A score, upon admittance; H score, the highest score throughout hospitalization; and E score, at the end of hospitalization. For each day of Brixia A, H or E score, the qSOFA (quick sepsis-related organ failure assessment) score was calculated, and the blood values were also considered. (3) Results: Brixia E score, C-reactive protein, GGT and LDH were much higher, while neutrophil count was much lower in autumn compared with spring critical-form pregnant patients. (4) Conclusions: the autumn infection generated more dramatic alterations than the spring infection in pregnant patients with critical forms of COVID-19. Larger studies with more numerous participants are required to confirm these results.

Development of COVID-19 severity assessment score in adults presenting with COVID-19 to the emergency department.

BACKGROUND: Critically-ill Covid-19 patients require extensive resources which can overburden a healthcare system already under strain due to a pandemic. A good disease severity prediction score can help allocate resources to where they are needed most. OBJECTIVES: We developed a Covid-19 Severity Assessment Score (CoSAS) to predict those patients likely to suffer from mortalities within 28 days of hospital admission. We also compared this score to Quick Sequential Organ Failure Assessment (qSOFA) in adults. METHODS: CoSAS includes the following 10 components: Age, gender, Clinical Frailty Score, number of comorbidities, Ferritin level, D-dimer level, neutrophil/lymphocyte ratio, C-reactive Protein levels, systolic blood pressure and oxygen saturation. Our study was a single center study with data collected via chart review and phone calls. 309 patients were included in the study. RESULTS: CoSAS proved to be a good score to predict Covid-19 mortality with an Area under the Curve (AUC) of 0.78. It also proved better than qSOFA (AUC of 0.70). More studies are needed to externally validate CoSAS. CONCLUSION: CoSAS is an accurate score to predict Covid-19 mortality in the Pakistani population.

Predictive Value of Sequential Organ Failure Assessment, Quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and New Early Warning Signs Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit.

Introduction: Various mortality predictive score models for coronavirus disease-2019 (COVID-19) have been deliberated. We studied how sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), acute physiology and chronic health evaluation II (APACHE II), and new early warning signs (NEWS-2) scores estimate mortality in COVID-19 patients. Materials and methods: We conducted a prospective cohort study of 53 patients with moderate-to-severe COVID-19. We calculated qSOFA, SOFA, APACHE II, and NEWS-2 on initial admission and re-evaluated on day 5. We performed logistic regression analysis to differentiate the predictors of qSOFA, SOFA, APACHE II, and NEWS-2 scores on mortality. Result: qSOFA, SOFA, APACHE II, and NEWS-2 scores on day 5 exhibited a difference between survivors and nonsurvivors (p <0.05), also between ICU and non-ICU admission (p <0.05). The initial NEWS-2 revealed a higher AUC value than the qSOFA, APACHE II, and SOFA score in estimating mortality (0.867; 0.83; 0.822; 0.794). In ICU, APACHE II score revealed a higher AUC value than the SOFA, NEWS-2, and qSOFA score (0.853; 0.832; 0.813; 0.809). Concurrently, evaluation on day 5 showed that qSOFA AUC had higher scores than the NEWS-2, APACHE II, and SOFA (0.979; 0.965; 0.939; 0.933) in predicting mortality, while SOFA and APACHE II AUC were higher in ICU admission than NEWS-2 and qSOFA (0.968; 0.964; 0.939; 0.934). According to the cutoff score, APACHE II on day 5 revealed the highest sensitivity and specificity in predicting the mortality (sensitivity 95.7%, specificity 86.7%). Conclusion: All scores signify good predictive values on COVID-19 patients mortality following the evaluation on the day 5. Nonetheless, APACHE-II appears to be the best at predicting mortality and ICU admission rate. How to cite this article: Asmarawati TP, Suryantoro SD, Rosyid AN, Marfiani E, Windradi C, Mahdi BA, et al. Predictive Value of Sequential Organ Failure Assessment, Quick Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and New Early Warning Signs Scores Estimate Mortality of COVID-19 Patients Requiring Intensive Care Unit. Indian J Crit Care Med 2022;26(4):464-471.

Predictive Value of SOFA and qSOFA for In-Hospital Mortality in COVID-19 Patients: A Single-Center Study in Romania.

Two years after the outbreak of the COVID-19 pandemic, the disease continues to claim victims worldwide. Assessing the disease's severity on admission may be useful in reducing mortality among patients with COVID-19. The present study was designed to assess the prognostic value of SOFA and qSOFA scoring systems for in-hospital mortality among patients with COVID-19. The study included 133 patients with COVID-19 proven by reverse transcriptase polymerase chain reaction (RT-PCR) admitted to the Municipal Emergency Clinical Hospital of Timisoara, Romania between 1 October 2020 and 15 March 2021. Data on clinical features and laboratory findings on admission were collected from electronic medical records and used to compute SOFA and qSOFA. Mean SOFA and qSOFA values were higher in the non-survivor group compared to survivors (3.5 vs. 1 for SOFA and 2 vs. 1 for qSOFA, respectively). Receiver operating characteristic (ROC) and area under the curve (AUC) analyses were performed to determine the discrimination accuracy, both risk scores being excellent predictors of in-hospital mortality, with ROC-AUC values of 0.800 for SOFA and 0.794 for qSOFA. The regression analysis showed that for every one-point increase in SOFA score, mortality risk increased by 1.82 and for every one-point increase in qSOFA score, mortality risk increased by 5.23. In addition, patients with SOFA and qSOFA above the cut-off values have an increased risk of mortality with ORs of 7.46 and 11.3, respectively. In conclusion, SOFA and qSOFA are excellent predictors of in-hospital mortality among COVID-19 patients. These scores determined at admission could help physicians identify those patients at high risk of severe COVID-19.

COVID-19 and C. auris: A Case-Control Study from a Tertiary Care Center in Lebanon.

Many healthcare centers around the world have reported the surge of Candida auris (C. auris) outbreaks during the COVID-19 pandemic, especially among intensive care unit (ICU) patients. This is a retrospective study conducted at the American University of Beirut Medical Center (AUBMC) between 1 October 2020 and 15 June 2021, to identify risk factors for acquiring C. auris in patients with severe COVID-19 infection and to evaluate the impact of C. auris on mortality in patients admitted to the ICU during that period. Twenty-four non-COVID-19 (COV-) patients were admitted to ICUs at AUBMC during that period and acquired C. auris (C. auris+/COV-). Thirty-two patients admitted with severe COVID-19 (COV+) acquired C. auris (C. auris+/COV+), and 130 patients had severe COVID-19 without C. auris (C. auris-/COV+). Bivariable analysis between the groups of (C. auris+/COV+) and (C. auris-/COV+) showed that higher quick sequential organ failure assessment (qSOFA) score (p < 0.001), prolonged length of stay (LOS) (p = 0.02), and the presence of a urinary catheter (p = 0.015) or of a central venous catheter (CVC) (p = 0.01) were associated with positive culture for C. auris in patients with severe COVID-19. The multivariable analysis showed that prolonged LOS (p = 0.008) and a high qSOFA score (p < 0.001) were the only risk factors independently associated with positive culture for C. auris. Increased LOS (p = 0.02), high "Candida score" (p = 0.01), and septic shock (p < 0.001) were associated with increased mortality within 30 days of positive culture for C. auris. Antifungal therapy for at least 7 days (p = 0.03) appeared to decrease mortality within 30 days of positive culture for C. auris. Only septic shock was associated with increased mortality in patients with C. auris (p = 0.006) in the multivariable analysis. C. auris is an emerging pathogen that constitutes a threat to the healthcare sector.

Performance of NEWS, qSOFA, and SIRS Scores for Assessing Mortality, Early Bacterial Infection, and Admission to ICU in COVID-19 Patients in the Emergency Department.

SARS-CoV-2 infection has a wide spectrum of presentations, from asymptomatic to pneumonia and sepsis. Risk scores have been used as triggers for protocols that combine several interventions for early management of sepsis. This study tested the accuracy of the score SIRS, qSOFA, and NEWS in predicting outcomes, including mortality and bacterial infection, in patients admitted to the emergency department (ED) during the COVID-19 pandemic. We described 2,473 cases of COVID-19 admitted to the ED of the largest referral hospital for severe COVID-19 in Brazil during the pandemic. SIRS, qSOFA and NEWS scores showed a poor performance as prognostic scores. However, NEWS score had a high sensitivity to predict in-hospital death (0.851), early bacterial infection (0.851), and ICU admission (0.868), suggesting that it may be a good screening tool for severe cases of COVID-19, despite its low specificity.

Retrospective evaluation of the use of quick Sepsis-related Organ Failure Assessment (qSOFA) as predictor of mortality and length of hospitalization in dogs with pyometra (2013-2019): 52 cases.

OBJECTIVE: To evaluate the prognostic utility of quick Sepsis-related Organ Failure Assessment (qSOFA) for prediction of in-hospital mortality and length of hospitalization in dogs with pyometra. DESIGN: Retrospective cohort study from February 2013 to April 2019 SETTING: Tertiary referral hospital ANIMALS: Fifty-two dogs referred with confirmed diagnosis of pyometra INTERVENTIONS: None MEASUREMENTS AND PRINCIPAL OUTCOMES: Sixty-five percent of dogs survived to discharge. A cut-off score of ≥2 for qSOFA was associated with in-hospital mortality (odds ratio 6.51 [95% CI: 1.35 - 31.3]) P = 0.019. The area under the receiver operator characteristic curve for a qSOFA score ≥ 2 for mortality was 0.72 (95% CI: 0.59-0.85), with a sensitivity of 77.8% and a specificity of 66.7%. The mean ± SD number of organs with dysfunction was significantly higher in dogs with a qSOFA score ≥2 1.76 ± 0.83 compared to dogs with a qSOFA score < 2 1.08 ± 1.09, P = 0.015. The presence of a qSOFA score ≥ 2 was associated with a longer time of hospitalization in survivors with a median (interquartile range) length of stay in qSOFA < 2 (48 [33]) hours versus qSOFA score ≥ 2 (78 [52]) hours, P = 0.027. CONCLUSIONS: In dogs with pyometra, the qSOFA score was associated with mortality and length of hospitalization. This score might be useful to improve the risk stratification in dogs with pyometra. Further studies are necessary to evaluate the predictive capacity of qSOFA in other septic patient populations.

Comparison of Early and Late Intubation in COVID-19 and Its Effect on Mortality.

BACKGROUND: Best practices for management of COVID-19 patients with acute respiratory failure continue to evolve. Initial debate existed over whether patients should be intubated in the emergency department or trialed on noninvasive methods prior to intubation outside the emergency department. OBJECTIVES: To determine whether emergency department intubations in COVID-19 affect mortality. METHODS: We conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test and required endotracheal intubation during their hospital course between 1 March 2020 and 1 June 2020. Patients were divided into two groups based on location of intubation: early intubation in the emergency department or late intubation performed outside the emergency department. Clinical and demographic information was collected including comorbid medical conditions, qSOFA score, and patient mortality. RESULTS: Of the 131 COVID-19-positive patients requiring intubation, 30 (22.9%) patients were intubated in the emergency department. No statistically significant difference existed in age, gender, ethnicity, or smoking status between the two groups at baseline. Patients in the early intubation cohort had a greater number of existing comorbidities (2.5, p = 0.06) and a higher median qSOFA score (3, p ≤ 0.001). Patients managed with early intubation had a statistically significant higher mortality rate (19/30, 63.3%) compared to the late intubation group (42/101, 41.6%). CONCLUSION: COVID-19 patients intubated in the emergency department had a higher qSOFA score and a greater number of pre-existing comorbidities. All-cause mortality in COVID-19 was greater in patients intubated in the emergency department compared to patients intubated outside the emergency department.

Are shock index, modified shock index, NLR and qSOFA useful in making COVID-19 intensive care follow-up decisions?

Aim: To meet the increasing intensive care and mechanical ventilator needs during the COVID-19 pandemic process, parameters that will enable rapid assessment and decision-making at the bedside are required in emergency services. The aim is to provide rational use of intensive care units by determining appropriate parameters that can be used to evaluate the intensive care follow-up indication. Material and Methods: Demographic data,vital signs, and hemogram results were recorded during the consultation in terms of intensive care follow-up requirements of the patients. The qSOFA, shock index, modified shock index, and the neutrophil-lymphocyte ratio were calculated. Results: Three hundred patients were included in the study.The median age was 69.2 years, 88% of the patients had at least one comorbid disease. The neutrophil-lymphocyte ratio was significant in predicting the need for intubation, but is not an independent risk factor. Male gender, qSOFA scores and need for intubation were predictors of intensive care mortality. Discussion: We found out that no scoring system can predict the requirement of intubation, but qSOFA is effective in showing mortality when making intensive care follow-up decisions for COVID-19 patients consulted in emergency departments.

Statistical analysis plan for the Steppedwedge Cluster Randomized trial of Electronic Early Notification of sepsis in hospitalized ward patients (SCREEN).

BACKGROUND: It is unclear whether screening for sepsis using an electronic alert in hospitalized ward patients improves outcomes. The objective of the Stepped-wedge Cluster Randomized Trial of Electronic Early Notification of Sepsis in Hospitalized Ward Patients (SCREEN) trial is to evaluate whether an electronic screening for sepsis compared to no screening among hospitalized ward patients reduces all-cause 90-day in-hospital mortality. METHODS AND DESIGN: This study is designed as a stepped-wedge cluster randomized trial in which the unit of randomization or cluster is the hospital ward. An electronic alert for sepsis was developed in the electronic medical record (EMR), with the feature of being active (visible to treating team) or masked (inactive in EMR frontend for the treating team but active in the backend of the EMR). Forty-five clusters in 5 hospitals are randomized into 9 sequences of 5 clusters each to receive the intervention (active alert) over 10 periods, 2 months each, the first being the baseline period. Data are extracted from EMR and are compared between the intervention (active alert) and control group (masked alert). During the study period, some of the hospital wards were allocated to manage patients with COVID-19. The primary outcome of all-cause hospital mortality by day 90 will be compared using a generalized linear mixed model with a binary distribution and a log-link function to estimate the relative risk as a measure of effect. We will include two levels of random effects to account for nested clustering within wards and periods and two levels of fixed effects: hospitals and COVID-19 ward status in addition to the intervention. Results will be expressed as relative risk with a 95% confidence interval. CONCLUSION: The SCREEN trial provides an opportunity for a novel trial design and analysis of routinely collected and entered data to evaluate the effectiveness of an intervention (alert) for a common medical problem (sepsis in ward patients). In this statistical analysis plan, we outline details of the planned analyses in advance of trial completion. Prior specification of the statistical methods and outcome analysis will facilitate unbiased analyses of these important clinical data. TRIAL REGISTRATION: ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019.

Severity of illness scores at presentation predict ICU admission and mortality in COVID-19.

BACKGROUND: The COVID-19 pandemic has overwhelmed hospital systems in multiple countries and necessitated caring for patients in atypical healthcare settings. The goal of this study was to ascertain if the conventional critical care severity scores qSOFA, SOFA, APACHE-II, and SAPS-II could predict which patients admitted to the hospital from an emergency department would eventually require intensive care. METHODS: This single-center, retrospective cohort study enrolled patients admitted to Vanderbilt University Hospital from the emergency room with symptomatic, confirmed COVID-19 infection between March 8, 2020 through May 15, 2020. Clinical phenotyping was performed by chart abstraction, and the correlation of the qSOFA, SOFA, APACHE-II, and SAPS-II scores for the primary endpoint of ICU admission and secondary endpoint of in-hospital mortality was evaluated. RESULTS: During the study period, 128 patients were admitted to Vanderbilt University Hospital from the emergency room with COVID-19. Of these, 39 patients eventually required intensive care; the remaining 89 were discharged from the medical ward. All severity of illness scores demonstrated at least moderate ability to identify patients who would die or require ICU admission. Of the three severity of illness scores assessed, the APACHE-II score performed best with an AUC of 0.851 (95% CI: 0.786 to 0.917) for identifying patient that would require ICU admission. No patient with an APACHE-II score at the time of presentation less than 8 or qSOFA of 0 required intensive care unit (ICU) admission. All patients with an APACHE-II score less than 10 or qSOFA score of 0 survived to hospital discharge. CONCLUSIONS: The APACHE-II score accurately predicts the eventual need for ICU admission. This may allow for risk-stratification of patients safe to treat in alternative health care settings and prognostic enrichment to accelerate clinical trials of COVID-19 therapies.

Severity Scores in COVID-19 Pneumonia: a Multicenter, Retrospective, Cohort Study.

BACKGROUND: Identification of patients on admission to hospital with coronavirus infectious disease 2019 (COVID-19) pneumonia who can develop poor outcomes has not yet been comprehensively assessed. OBJECTIVE: To compare severity scores used for community-acquired pneumonia to identify high-risk patients with COVID-19 pneumonia. DESIGN: PSI, CURB-65, qSOFA, and MuLBSTA, a new score for viral pneumonia, were calculated on admission to hospital to identify high-risk patients for in-hospital mortality, admission to an intensive care unit (ICU), or use of mechanical ventilation. Area under receiver operating characteristics curve (AUROC), sensitivity, and specificity for each score were determined and AUROC was compared among them. PARTICIPANTS: Patients with COVID-19 pneumonia included in the SEMI-COVID-19 Network. KEY RESULTS: We examined 10,238 patients with COVID-19. Mean age of patients was 66.6 years and 57.9% were males. The most common comorbidities were as follows: hypertension (49.2%), diabetes (18.8%), and chronic obstructive pulmonary disease (12.8%). Acute respiratory distress syndrome (34.7%) and acute kidney injury (13.9%) were the most common complications. In-hospital mortality was 20.9%. PSI and CURB-65 showed the highest AUROC (0.835 and 0.825, respectively). qSOFA and MuLBSTA had a lower AUROC (0.728 and 0.715, respectively). qSOFA was the most specific score (specificity 95.7%) albeit its sensitivity was only 26.2%. PSI had the highest sensitivity (84.1%) and a specificity of 72.2%. CONCLUSIONS: PSI and CURB-65, specific severity scores for pneumonia, were better than qSOFA and MuLBSTA at predicting mortality in patients with COVID-19 pneumonia. Additionally, qSOFA, the simplest score to perform, was the most specific albeit the least sensitive.

Clinical Characteristics and Risk Factors for Death of Hospitalized Patients With COVID-19 in a Community Hospital: A Retrospective Cohort Study.

OBJECTIVE: To describe the clinical characteristics, outcomes, and risk factors for death of patients with coronavirus disease 2019 (COVID-19) in a community hospital setting. PATIENTS AND METHODS: This single-center retrospective cohort study included 313 adult patients with laboratory-confirmed COVID-19 admitted to a community hospital in Cook County, Illinois, from March 1, 2020, to May 25, 2020. Demographics, medical history, underlying comorbidities, symptoms, signs, laboratory findings, imaging studies, management, and progression to discharge or death data were collected and analyzed. RESULTS: Of 313 patients, the median age was 68 years (interquartile range, 59.0-78.5 years; range, 19-98 years), 182 (58.1%) were male, 119 (38%) were white, and 194 (62%) were admitted from a long-term care facility (LTCF). As of May 25, 2020, there were 212 (67.7%) survivors identified, whereas 101 (32.3%) nonsurvivors were identified. Multivariable Cox regression analysis showed increasing hazards of inpatient death associated with older age (hazard ratio [HR] 1.02; 95% CI, 1.01-1.04), LTCF residence (HR, 3.23; 95% CI, 1.68-6.20), and quick Sequential Organ Failure Assessment scores (HR, 2.59; 95% CI, 1.78-3.76). CONCLUSION: In this single-center retrospective cohort study of 313 adult patients hospitalized with COVID-19 illness in a community hospital in Cook County, Illinois, older patients, LTCF residents, and patients with high quick Sequential Organ Failure Assessment scores were found to have worse clinical outcomes and increased risk of death.

Predicting severe COVID-19 in the Emergency Department.

BACKGROUND: COVID-19 may lead to severe disease, requiring intensive care treatment and challenging the capacity of health care systems. The aim of this study was to compare the ability of commonly used scoring systems for sepsis and pneumonia to predict severe COVID-19 in the emergency department. METHODS: Prospective, observational, single centre study in a secondary/tertiary care hospital in Oslo, Norway. Patients were assessed upon hospital admission using the following scoring systems; quick Sequential Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome criteria (SIRS), National Early Warning Score 2 (NEWS2), CURB-65 and Pneumonia Severity index (PSI). The ratio of arterial oxygen tension to inspiratory oxygen fraction (P/F-ratio) was also calculated. The area under the receiver operating characteristics curve (AUROC) for each scoring system was calculated, along with sensitivity and specificity for the most commonly used cut-offs. Severe disease was defined as death or treatment in ICU within 14 days. RESULTS: 38 of 175 study participants developed severe disease, 13 (7%) died and 29 (17%) had a stay at an intensive care unit (ICU). NEWS2 displayed an AUROC of 0.80 (95% confidence interval 0.72-0.88), CURB-65 0.75 (0.65-0.84), PSI 0.75 (0.65-0.84), SIRS 0.70 (0.61-0.80) and qSOFA 0.70 (0.61-0.79). NEWS2 was significantly better than SIRS and qSOFA in predicating severe disease, and with a cut-off of5 points, had a sensitivity and specificity of 82% and 60%, respectively. CONCLUSION: NEWS2 predicted severe COVID-19 disease more accurately than SIRS and qSOFA, but not significantly better than CURB65 and PSI. NEWS2 may be a useful screening tool in evaluating COVID-19 patients during hospital admission. TRIAL REGISTRATION: : ClinicalTrials.gov Identifier: NCT04345536. (https://clinicaltrials.gov/ct2/show/NCT04345536).

Predicting intensive care unit admission and death for COVID-19 patients in the emergency department using early warning scores.

AIMS: To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED). METHODS: In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated. RESULTS: We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes. CONCLUSION: In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration.