Real-world evaluation of rapid and laboratory-free COVID-19 triage for emergency care: external validation and pilot deployment of artificial intelligence driven screening.

BACKGROUND: Uncertainty in patients' COVID-19 status contributes to treatment delays, nosocomial transmission, and operational pressures in hospitals. However, the typical turnaround time for laboratory PCR remains 12-24 h and lateral flow devices (LFDs) have limited sensitivity. Previously, we have shown that artificial intelligence-driven triage (CURIAL-1.0) can provide rapid COVID-19 screening using clinical data routinely available within 1 h of arrival to hospital. Here, we aimed to improve the time from arrival to the emergency department to the availability of a result, do external and prospective validation, and deploy a novel laboratory-free screening tool in a UK emergency department. METHODS: We optimised our previous model, removing less informative predictors to improve generalisability and speed, developing the CURIAL-Lab model with vital signs and readily available blood tests (full blood count [FBC]; urea, creatinine, and electrolytes; liver function tests; and C-reactive protein) and the CURIAL-Rapide model with vital signs and FBC alone. Models were validated externally for emergency admissions to University Hospitals Birmingham, Bedfordshire Hospitals, and Portsmouth Hospitals University National Health Service (NHS) trusts, and prospectively at Oxford University Hospitals, by comparison with PCR testing. Next, we compared model performance directly against LFDs and evaluated a combined pathway that triaged patients who had either a positive CURIAL model result or a positive LFD to a COVID-19-suspected clinical area. Lastly, we deployed CURIAL-Rapide alongside an approved point-of-care FBC analyser to provide laboratory-free COVID-19 screening at the John Radcliffe Hospital (Oxford, UK). Our primary improvement outcome was time-to-result, and our performance measures were sensitivity, specificity, positive and negative predictive values, and area under receiver operating characteristic curve (AUROC). FINDINGS: 72 223 patients met eligibility criteria across the four validating hospital groups, in a total validation period spanning Dec 1, 2019, to March 31, 2021. CURIAL-Lab and CURIAL-Rapide performed consistently across trusts (AUROC range 0·858-0·881, 95% CI 0·838-0·912, for CURIAL-Lab and 0·836-0·854, 0·814-0·889, for CURIAL-Rapide), achieving highest sensitivity at Portsmouth Hospitals (84·1%, Wilson's 95% CI 82·5-85·7, for CURIAL-Lab and 83·5%, 81·8-85·1, for CURIAL-Rapide) at specificities of 71·3% (70·9-71·8) for CURIAL-Lab and 63·6% (63·1-64·1) for CURIAL-Rapide. When combined with LFDs, model predictions improved triage sensitivity from 56·9% (51·7-62·0) for LFDs alone to 85·6% with CURIAL-Lab (81·6-88·9; AUROC 0·925) and 88·2% with CURIAL-Rapide (84·4-91·1; AUROC 0·919), thereby reducing missed COVID-19 cases by 65% with CURIAL-Lab and 72% with CURIAL-Rapide. For the prospective deployment of CURIAL-Rapide, 520 patients were enrolled for point-of-care FBC analysis between Feb 18 and May 10, 2021, of whom 436 received confirmatory PCR testing and ten (2·3%) tested positive. Median time from arrival to a CURIAL-Rapide result was 45 min (IQR 32-64), 16 min (26·3%) sooner than with LFDs (61 min, 37-99; log-rank p<0·0001), and 6 h 52 min (90·2%) sooner than with PCR (7 h 37 min, 6 h 5 min to 15 h 39 min; p<0·0001). Classification performance was high, with sensitivity of 87·5% (95% CI 52·9-97·8), specificity of 85·4% (81·3-88·7), and negative predictive value of 99·7% (98·2-99·9). CURIAL-Rapide correctly excluded infection for 31 (58·5%) of 53 patients who were triaged by a physician to a COVID-19-suspected area but went on to test negative by PCR. INTERPRETATION: Our findings show the generalisability, performance, and real-world operational benefits of artificial intelligence-driven screening for COVID-19 over standard-of-care in emergency departments. CURIAL-Rapide provided rapid, laboratory-free screening when used with near-patient FBC analysis, and was able to reduce the number of patients who tested negative for COVID-19 but were triaged to COVID-19-suspected areas. FUNDING: The Wellcome Trust, University of Oxford Medical and Life Sciences Translational Fund.

Impact of the COVID-19 pandemic on corticosteroid injection services: A National Survey of Members of the British Society of Skeletal Radiologists (BSSR).

OBJECTIVE: To describe the restructuring of services by British radiologists in response to evolving national guidelines and highlight the impact of the COVID-19 pandemic on the treatment of musculoskeletal (MSK) conditions. METHODS: An online anonymised survey was distributed via the British Society of Skeletal Radiology (BSSR) members forum in November 2020. Responses were collated using a standardised Google form including 21 questions. RESULTS: 135 members of the BSSR completed the survey. 85% of respondents stopped performing corticosteroid injections (CSI) during the initial lockdown of the pandemic. This was primarily influenced by national guidelines. The majority of respondents initially abstained from offered CSI procedures, then by November 2020, 69% of respondents were providing CSI for high and low risk patients, 23% were only providing CSI for low-risk patients with 8% still not performing any CSI. 40% of respondents reported routinely obtaining specific written consent regarding the risk of COVID-19. Approximately, 11,000 CSI were performed by respondents between March and November 2020 with no reported significant COVID-19-related complications. Over 80% of BSSR members reported that the number of CSI procedures that they performed dropped by more than 80% compared to usual. 73% of respondents reported an increased backlog of patients awaiting treatment. The average waiting time for routine outpatient CSI treatment was > 12 weeks in 53% of responses, compared to 34% the previous year. CONCLUSION: The COVID-19 pandemic has had a significant impact on the clinical practices of MSK radiologists in the UK. Our survey highlights the rapid response of BSSR members as national guidelines evolved. Currently, the majority of respondents are performing CSI for musculoskeletal conditions when clinically indicated, with enhanced consent. However, the pandemic has resulted in increased waiting times - delaying the treatment of patients who may be suffering with significant pain and disability. Further research is warranted to provide guidance around both service recovery and provision of CSI around COVID-19 vaccination schedules. ADVANCES IN KNOWLEDGE: BSSR members responded rapidly to changing guidelines during the COVID-19 pandemic. The majority of respondents are currently performing CSI when clinically indicated. The pandemic has resulted in a significant increase in waiting times which will have a significant impact on UK musculoskeletal services.

Corticosteroid injections during the COVID-19 pandemic: experience from a UK centre.

AIMS: To describe the incidence of adverse clinical outcomes related to COVID-19 infection following corticosteroid injections (CSI) during the COVID-19 pandemic. To describe the incidence of positive SARS-CoV-2 reverse transcriptase polymerase chain reaction (RT-PCR) testing, positive SARS-COV2 IgG antibody testing or positive imaging findings following CSI at our institution during the COVID-19 pandemic. METHODS: A retrospective observational study was undertaken of consecutive patients who had CSI in our local hospitals between 1 February and 30June 2020. Electronic patient medical records (EPR) and radiology information system (RIS) database were reviewed. SARS-CoV-2 RT-PCR testing, SARS-COV2 IgG antibody testing, radiological investigations, patient management, and clinical outcomes were recorded. Lung findings were categorized according to the British Society of Thoracic Imaging (BSTI) guidelines. Reference was made to the incidence of lab-confirmed COVID-19 cases in our region. RESULTS: Overall, 1,656 lab-confirmed COVID-19 cases were identified in our upper tier local authority (UTLA), a rate of 306.6 per 100,000, as of 30June 2020. A total of 504 CSI injections were performed on 443 patients between 1 February and 30June 2020. A total of 11 RT-PCR tests were performed on nine patients (2% of those who had CSI), all of which were negative for SARS-CoV-2 RNA, and five patients (1.1%) received an SARS-CoV-2 IgG antibody test, of which 2 (0.5%) were positive consistent with prior COVID-19 infection, however both patients were asymptomatic. Seven patients (1.6%) had radiological investigations for respiratory symptoms. One patient with indeterminate ground glass change was identified. CONCLUSION: The incidence of positive COVID-19 infection following corticosteroid injections was very low in our cohort and no adverse clinical outcomes related to COVID-19 infection following CSI were identified. Our findings are consistent with CSI likely being low risk during the COVID-19 pandemic. The results of this small observational study are supportive of the current multi-society guidelines regarding the judicious use of CSI.Cite this article: Bone Joint Open 2020;1-9:605-611.