A clinical risk score to identify patients with COVID-19 at high risk of critical care admission or death: An observational cohort study

Abstract

Background: The COVID-19 pandemic continues to escalate. There is urgent need to stratify patients. Understanding risk of deterioration will assist in admission and discharge decisions, and help selection for clinical studies to indicate where risk of therapy-related complications is justified. Methods: An observational cohort of patients acutely admitted to two London hospitals with COVID-19 and positive SARS-CoV-2 swab results was assessed. Demographic details, clinical data, comorbidities, blood parameters and chest radiograph severity scores were collected from electronic health records. Endpoints assessed were critical care admission and death. A risk score was developed to predict outcomes. Findings: Analyses included 1,157 patients. Older age, male sex, comorbidities, respiratory rate, oxygenation, radiographic severity, higher neutrophils, higher CRP and lower albumin at presentation predicted critical care admission and mortality. Non-white ethnicity predicted critical care admission but not death. Social deprivation was not predictive of outcome. A risk score was developed incorporating twelve characteristics: age > 40, male, non-white ethnicity, oxygen saturations < 93%, radiological severity score > 3, neutrophil count > 8.0 x10 9 /L, CRP > 40 mg/L, albumin < 34 g/L, creatinine > 100 μmol/L, diabetes mellitus, hypertension and chronic lung disease. Risk scores of 4 or higher corresponded to a 28-day cumulative incidence of critical care admission or death of 40.7% (95% CI: 37.1 to 44.4), versus 12.4% (95% CI: 8.2 to 16.7) for scores less than 4. Interpretation: Our study identified predictors of critical care admission and death in people admitted to hospital with COVID-19. These predictors were incorporated into a risk score that will inform clinical care and stratify patients for clinical trials.

Deciphering the Role of Host Genetics in Susceptibility to Severe COVID-19

“…So far, only a limited number of studies have looked for an association between HLA haplotypes and genetic susceptibility or resistance to SARS coronavirus infection. However, an impact of HLA haplotypes may identify some of the unexplained differences in disease severity and mortality observed across different countries and different population ethnicities (150)(151)(152)(153)(154). Allele typing of 37 probable SARS patients in Taiwan identified an association between HLA-B * 4601 and SARS-CoV infection (155); however, this was not confirmed in a study of 90 serologically confirmed SARS-CoV patients in Hong Kong (156,157).…”

A validated, real-time prediction model for favorable outcomes in hospitalized COVID-19 patients

“…Of the 30 models, 23 were trained on patients in China , 2 were trained on patients in the United States 30,31 , and 5 were trained on patients in South Korea 32 or Europe [33][34][35][36] . Only 8 of the models underwent validation on either held-out or external datasets 7,10,14,18,19,24,26,36 , and 1 underwent prospective validation . No model predicted favorable outcomes and no studies reported clinical implementation.…”

CURB-65 plus Hypoalbuminemia: a new score system for prediction of the in-hospital mortality risk in patients with SARS-CoV-2 pneumonia

“…While several scores have been investigated and further validated for optimal for the management of CAP, for COVID-19 patients drawing a de nite conclusion among the many proposed prognostic biomarkers and scores appears to be very di cult [13][14][15][16][17]. The CALL score and a risk score including several parameters calculated at hospital admission (age, sex, ethnicity, oxygen saturations, radiology, neutrophil count, CRP, albumin, creatinine, comorbidities) were recently developed to predict 28-day mortality and ICU admission [9,16]. Furthermore, a predictive model (named the HNC-LL score and based on neutrophil count, lymphocyte count, LDH level, CRP level and hypertension) was also developed and validated to enable early and accurate identi cation of patients with SARS-CoV-2 infection at a high risk of severe disease [34].…”

“…Taking into consideration the abovementioned scores, we decided to exclude from our analysis the score proposed by Galloway et al since disease severity was radiologically assessed with adoption of on chest radiograph examination that was replaced by chest CT in our patients population [9]. The HNC-LL score was highly predictive of severe disease, with the de nition of severity including both subjects requiring intensive care and those with respiratory distress but not requiring ICU admission [34].…”

“…During SARS-CoV-2 pneumonia a percentage of patients with mild symptoms might exhibit a sudden progression to severe or critical disease requiring intensive care [7,8]. In the latter case, the infection follows a characteristic pattern, with the development of respiratory failure and multi-organ dysfunction generally 7-12 days following symptom onset [9]. Therefore, there is the urgent need to consider simple and accurate predictors of adverse outcomes in order to early identify patients at risk of disease progression or death.…”