ABSTRACT
PURPOSE: With uncertain prognostic utility of existing predictive scoring systems for COVID-19-related illness, the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) 4C Mortality Score was developed by the International Severe Acute Respiratory and Emerging Infection Consortium as a COVID-19 mortality prediction tool. We sought to externally validate this score among critically ill patients admitted to an intensive care unit (ICU) with COVID-19 and compare its discrimination characteristics to that of the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores. METHODS: We enrolled all consecutive patients admitted with COVID-19-associated respiratory failure between 5 March 2020 and 5 March 2022 to our university-affiliated and intensivist-staffed ICU (Jewish General Hospital, Montreal, QC, Canada). After data abstraction, our primary outcome of in-hospital mortality was evaluated with an objective of determining the discriminative properties of the ISARIC 4C Mortality Score, using the area under the curve of a logistic regression model. RESULTS: A total of 429 patients were included, 102 (23.8%) of whom died in hospital. The receiver operator curve of the ISARIC 4C Mortality Score had an area under the curve of 0.762 (95% confidence interval [CI], 0.717 to 0.811), whereas those of the SOFA and APACHE II scores were 0.705 (95% CI, 0.648 to 0.761) and 0.722 (95% CI, 0.667 to 0.777), respectively. CONCLUSIONS: The ISARIC 4C Mortality Score is a tool that had a good predictive performance for in-hospital mortality in a cohort of patients with COVID-19 admitted to an ICU for respiratory failure. Our results suggest a good external validity of the 4C score when applied to a more severely ill population.
RéSUMé: OBJECTIF: Compte tenu de l'utilité pronostique incertaine des systèmes de notation prédictive existants pour les maladies liées à la COVID-19, le score de mortalité ISARIC 4C a été mis au point par l'International Severe Acute Respiratory and Emerging Infection Consortium en tant qu'outil de prédiction de la mortalité associée à la COVID-19. Nous avons cherché à valider en externe ce score chez les patient·es gravement malades atteint·es de COVID-19 admis·es dans une unité de soins intensifs (USI) et à comparer ses caractéristiques de discrimination à celles des scores APACHE II (Acute Physiology and Chronic Health Evaluation) et SOFA (Sequential Organ Failure Assessment). MéTHODE: Nous avons recruté toutes les personnes consécutives admises pour insuffisance respiratoire associée à la COVID-19 entre le 5 mars 2020 et le 5 mars 2022 dans notre unité de soins intensifs affiliée à l'université et dotée d'intensivistes (Hôpital général juif, Montréal, QC, Canada). Après l'abstraction des données, notre critère d'évaluation principal de mortalité à l'hôpital a été évalué dans le but de déterminer les propriétés discriminatives du score de mortalité ISARIC 4C, en utilisant la surface sous la courbe d'un modèle de régression logistique. RéSULTATS: Au total, 429 patient·es ont été inclus·es, dont 102 (23,8 %) sont décédé·es à l'hôpital. La fonction d'efficacité du récepteur (courbe ROC) du score de mortalité ISARIC 4C avait une surface sous la courbe de 0,762 (intervalle de confiance [IC] à 95 %, 0,717 à 0,811), tandis que celles des scores SOFA et APACHE II étaient de 0,705 (IC 95%, 0,648 à 0,761) et 0,722 (IC 95%, 0,667 à 0,777), respectivement. CONCLUSION: Le score de mortalité ISARIC 4C est un outil qui a affiché une bonne performance prédictive de la mortalité à l'hôpital dans une cohorte de patient·es atteint·es de COVID-19 admis·es dans une unité de soins intensifs pour insuffisance respiratoire. Nos résultats suggèrent une bonne validité externe du score 4C lorsqu'il est appliqué à une population plus gravement malade.
Subject(s)
COVID-19 , Humans , Cohort Studies , Hospital Mortality , Canada/epidemiology , Intensive Care Units , Retrospective Studies , Prognosis , ROC CurveABSTRACT
BACKGROUND: Recent literature reports a decrease in healthcare-seeking behaviours by adults during the Covid-19 pandemic. Given that emergency general surgery (GS) conditions are often associated with high morbidity and mortality if left untreated, the objective of this study was to describe and quantify the impact of the Covid-19 pandemic on rates of emergency department (ED) utilization and hospital admission due to GS conditions. METHODS: This cohort study involved the analysis of an institutional database and retrospective chart review. We identified adult patients presenting to the ED in a network of three teaching hospitals in Montreal, Canada during the first wave of the Covid-19 pandemic (March13-May13, 2020) and a control pre-pandemic period (March13-May13, 2019). Patients with GS conditions were included in the analysis. ED utilization rates, admission rates and 30-day outcomes were compared between the two periods using multivariate regression analysis. RESULTS: During the pandemic period, 258 patients presented to ED with a GS diagnosis compared to 351 patients pre-pandemically (adjusted rate ratio (aRR) 0.75; p < 0.001). Rate of hospital admission during the pandemic was also significantly lower (aRR = 0.77, p < 0.001). Patients had a significantly shorter ED stay during the pandemic (adjusted mean difference 5.0 h; p < 0.001). Rates of operative management during the pandemic were preserved compared to the pre-pandemic period. There were no differences in 30-day complications (adjusted odds ratio (aOR) 1.46; p = 0.07), ED revisits (aOR 1.10; p = 0.66) and (re)admissions (aOR 1.42; p = 0.22) between the two periods. CONCLUSION: There was a decrease in rates of ED utilization and hospital admissions due to GS conditions during the first wave of the Covid -19 pandemic; however, rates of operative management, complications and healthcare reutilization were unchanged. Although our findings are not generalizable to patients who did not seek healthcare, it was possible to successfully uphold institutional standards of care once patients presented to the ED.
