Development and validation of the ISARIC 4C Deterioration model for adults hospitalised with COVID-19: a prospective cohort study

Rk, Gupta; Harrison, Ewen M; Ho, Antonia; Docherty, Annemarie B; Knight, Stephen R; Smeden, Maarten van; Abubakar, Ibrahim; Lipman, Marc; Quartagno, Matteo; Pius, Riinu; Buchan, Iain; Carson, Gail; Drake, Thomas M; Dunning, Jake; Fairfield, Cameron J; Gamble, Carrol; Green, Christopher; Halpin, Sophie; Hardwick, Hayley; Holden, Karl A; Horby, Peter; Jackson, Clare; McLean, Kenneth A; Merson, Laura; Nguyen‐Van‐Tam, Jonathan S; Norman, Lisa; Olliaro, Piero; Pritchard, Mark G; Russell, Clark D; Scott-Brown, James; Shaw, Catherine; Sheikh, Aziz; Solomon, Tom; Sudlow, Cathie; Swann, Olivia; Turtle, Lance; Openshaw, Peter; Baillie, J Kenneth; Semple, Malcolm G; Noursadeghi, Mahdad; Investigators, Isaric C

doi:10.1016/s2213-2600(20)30559-2

Cited by 175 publications

(223 citation statements)

References 25 publications

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“…critical care provision within a trust). Greater illness severity at presentation is thought to be associated with poorer outcomes in patients with COVID-19 [25,26]. However, illness severity at presentation is likely to have varied over time and our analysis is one of very few to adjust for temporal trends.…”

Section: Discussionmentioning

confidence: 99%

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme

Gray¹,

Navaratnam²,

Day³

et al. 2021

EClinicalMedicine

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Background: A key first step in optimising COVID-19 patient outcomes during future case-surges is to learn from the experience within individual hospitals during the early stages of the pandemic. The aim of this study was to investigate the extent of variation in COVID-19 outcomes between National Health Service (NHS) hospital trusts and regions in England using data from MarchÀJuly 2020. Methods: This was a retrospective observational study using the Hospital Episode Statistics administrative dataset. Patients aged 18 years who had a diagnosis of COVID-19 during a hospital stay in England that was completed between March 1st and July 31st, 2020 were included. In-hospital mortality was the primary outcome of interest. In secondary analysis, critical care admission, length of stay and mortality within 30 days of discharge were also investigated. Multilevel logistic regression was used to adjust for covariates. Findings: There were 86,356 patients with a confirmed diagnosis of COVID-19 included in the study, of whom 22,944 (26.6%) died in hospital with COVID-19 as the primary cause of death. After adjusting for covariates, the extent of the variation in-hospital mortality rates between hospital trusts and regions was relatively modest. Trusts with the largest baseline number of beds and a greater proportion of patients admitted to critical care had the lowest in-hospital mortality rates. Interpretation: There is little evidence of clustering of deaths within hospital trusts. There may be opportunities to learn from the experience of individual trusts to help prepare hospitals for future case-surges.

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Section: Discussionmentioning

confidence: 99%

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme

Gray¹,

Navaratnam²,

Day³

et al. 2021

EClinicalMedicine

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“…This scale comprised of 4 levels of severity which were relevant to our in-hospital cohort; level 3 - did not receive supplemental oxygen, level 4 - received supplemental oxygen, level 5 - received high flow oxygen or NIV non-invasive ventilation (HFNC, NIV), and levels 6 and 7 - received invasive mechanical ventilation or admission to critical care) 23 . We also used the WHO severity scale to account for in-hospital severity in our modelling approach 23,24 .…”

Section: Methodsmentioning

confidence: 99%

Long Covid in adults discharged from UK hospitals after Covid-19: A prospective, multicentre cohort study using the ISARIC WHO Clinical Characterisation Protocol

Sigfrid

Drake

Pauley

et al. 2021

Preprint

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Structured Abstract Objectives: The long-term consequences of severe Covid-19 requiring hospital admission are not well characterised. The objective of this study was to establish the long-term effects of Covid-19 following hospitalisation and the impact these may have on patient reported outcome measures. Design: A multicentre, prospective cohort study with at least 3 months follow-up of participants admitted to hospital between 5th February 2020 and 5th October 2020. Setting: 31 hospitals in the United Kingdom. Participants: 327 hospitalised participants discharged alive from hospital with confirmed/high likelihood SARS-CoV-2 infection. Main outcome measures and comparisons: The primary outcome was self-reported recovery at least ninety days after initial Covid-19 symptom onset. Secondary outcomes included new symptoms, new or increased disability (Washington group short scale), breathlessness (MRC Dyspnoea scale) and quality of life (EQ5D-5L). We compared these outcome measures across age, comorbidity status and in-hospital Covid-19 severity to identify groups at highest risk of developing long-term difficulties. Multilevel logistic and linear regression models were built to adjust for the effects of patient and centre level risk factors on these outcomes. Results: In total 53.7% (443/824) contacted participants responded, yielding 73.8% (327/443) responses with follow-up of 90 days or more from symptom onset. The median time between symptom onset of initial illness and completing the participant questionnaire was 222 days (Interquartile range (IQR) 189 to 269 days). In total, 54.7% (179/327) of participants reported they did not feel fully recovered. Persistent symptoms were reported by 93.3% (305/325) of participants, with fatigue the most common (82.8%, 255/308), followed by breathlessness (53.5%, 175/327). 46.8% (153/327) reported an increase in MRC dyspnoea scale of at least one grade. New or worse disability was reported by 24.2% (79/327) of participants. Overall (EQ5D-5L) summary index was significantly worse at the time of follow-up (median difference 0.1 points on a scale of 0 to 1, IQR: -0.2 to 0.0). Females under the age of 50 years were five times less likely to report feeling recovered (adjusted OR 5.09, 95% CI 1.64 to 15.74), were more likely to have greater disability (adjusted OR 4.22, 95% CI 1.12 to 15.94), twice as likely to report worse fatigue (adjusted OR 2.06, 95% CI 0.81 to 3.31) and seven times more likely to become more breathless (adjusted OR 7.15, 95% CI 2.24 to 22.83) than men of the same age. Conclusions: Survivors of Covid-19 experienced long-term symptoms, new disability, increased breathlessness, and reduced quality of life. These findings were present even in young, previously healthy working age adults, and were most common in younger females. Policymakers should fund further research to identify effective treatments for long-Covid and ensure healthcare, social care and welfare support is available for individuals with long-Covid.

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“…These scores are validated risk stratification tools that predict in-hospital mortality or in-hospital clinical deterioration (defined as any requirement for ventilator support or critical care, or death) for hospitalised covid-19 patients in the UK. 13,14 The mortality score consists of: gender, number of comorbidities, Glasgow Coma score (GCS), age, respiratory rate, admission oxygen saturations, serum urea, C-reactive protein (CRP) and lymphocyte count. The deterioration score consists of: nosocomial covid-19, gender, number of comorbidities, radiographic chest infiltrates, whether the patient was receiving oxygen, GCS, age, respiratory rate, admission oxygen saturations, urea, CRP and lymphocyte count.…”

Section: Methodsmentioning

confidence: 99%

Exhaled SARS-CoV-2 quantified by face-mask sampling in hospitalised patients with covid-19

Williams

Pan²,

Decker³

et al. 2020

Preprint

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Background Nasopharyngeal samples (NPS) are the mainstay of COVID-19 diagnosis. However, the extent to which assay signals relate to exhaled virus is unknown. We investigated the use of novel, non-invasive face-mask sampling (FMS) to detect exhaled SARS-CoV-2 RNA in two studies. Methods In an outbreak study (cohort 1), we performed FMS and NPS for 21 consecutive days after diagnosis on six healthcare workers who were screened positive for SARS-CoV-2. In a second hospitalised cohort (cohort 2), we performed FMS on 47 patients within 24 hours of a positive diagnosis. COVID-19 severity was graded according to WHO recommendations. Findings In cohort 1, SARS-COV-2 was detected by FMS in 10/40 (25%) samples (4/6 individuals), with no correlation between NPS and FMS RNA signals. All samples were negative by day 14 post diagnosis. Sustained FMS positivity with higher viral RNA signals showed a trend towards disease severity. In cohort 2, 19/47 (40%) individuals exhaled SARS-CoV-2 RNA extending over five orders of magnitude. FMS positive participants were older (positive: median age [IQR] 71 [61-84] vs negative: 61 [45-73], p=0.04) with more comorbidities (positive: 2 [1-3] vs negative: 1 [0-2], p<0.001) and have active cough (positive: 68% vs negative: 24%, p=0.003) and breathlessness (positive: 74% vs negative: 32%, p=0.005) during sampling, compared to FMS negative patients. Of five patients who were FMS positive and asymptomatic at time of sampling, two died of severe COVID-19 pneumonia within one month of follow up. Interpretation FMS detects exhaled SARS-COV-2, with stronger signals in those who develop severe disease.

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Development and validation of the ISARIC 4C Deterioration model for adults hospitalised with COVID-19: a prospective cohort study

Cited by 175 publications

References 25 publications

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme

Variability in COVID-19 in-hospital mortality rates between national health service trusts and regions in England: A national observational study for the Getting It Right First Time Programme

Long Covid in adults discharged from UK hospitals after Covid-19: A prospective, multicentre cohort study using the ISARIC WHO Clinical Characterisation Protocol

Exhaled SARS-CoV-2 quantified by face-mask sampling in hospitalised patients with covid-19

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