Evaluation of triage methods used to select patients with suspected pandemic influenza for hospital admission: cohort study

Abstract

*Corresponding authorthree survivors who required respiratory support. The five patients with poor outcomes had CURB-65 scores of zero, one (three cases) and two, and PMEWS scores of one, five, six, seven and eight. The swine flu hospital pathway was positive in three out of five cases. The C-statistic for each method was CURB-65 0.78 [95% confidence interval (CI) 0.58 to 0.99], PMEWS 0.77 (95% CI 0.55 to 0.99) and the swine flu hospital pathway 0.70 (95% CI 0.45 to 0.96). Patients with a higher CURB-65 score were more likely to be admitted (p < 0.001): 25 out of 101 (25%) with a score of zero, 11 out of 24 (46%) with a score of one, 7 out of 8 (88%) with a score of two, and the patient with a score of three were admitted. Admitted patients had a higher mean PMEWS score (4.6 vs 2.0, p < 0.001). The C-statistics for CURB-65, PMEWS and the swine flu hospital pathway in adults in terms of discriminating between those admitted and discharged were 0.65 (95% CI 0.54 to 0.76), 0.76 (95% CI 0.66 to 0.86) and 0.62 (95% CI 0.51 to 0.72) respectively. Limitations: The 2009 H1N1 pandemic was much smaller and less severe than predicted and resulted in a lack of sufficient data.

The Swine Flu Triage (SwiFT) study: development and ongoing refinement of a triage tool to provide regular information to guide immediate policy and practice for the use of critical care services during the H1N1 swine influenza pandemic

“…38 A complementary NIHR-funded study evaluating triage for hospital admission during the H1N1 pandemic also noted low CURB-65 scores. 29 Of 134 adult patients assessed in the emergency department, 101 (75%) had a CURB-65 score of 0, and 24 (18%) had a score of 1, with only nine patients (7%) having a score of ≥ 2. Of those with a score of 0, 25% were admitted to hospital, and 46% of those with a score of 1.…”

“…These results seem to support findings from an emergency department cohort that CURB-65 is an unreliable triage tool in this setting. 29 Some of the poor performance of CURB-65 could be attributed to the fact that it was developed to triage patients for admission to hospital (a different triage step in the care pathway to that considered in SwiFT).…”

Development of processes allowing near real-time refinement and validation of triage tools during the early stage of an outbreak in readiness for surge: the FLU-CATs Study

“…CATs were developed by paediatric and adult expert clinical development groups drawing on evidence that supports the recognition of severe influenza and severe pneumonia in the community in adults and children in resource-limited settings, severe chronic obstructive pulmonary disease in adults, potentially serious feverish illness in children and severe bronchiolitis in infants. 5,[13][14][15][16][17][18][19][20][21][22] Clinicians were warned not to use the CATs and the pathways unless the local situation precluded normal admission and discharge processes.…”

“…[20,22] The validity and utility of using PMEWs, CATs (both triage tools) and CURB-65 (a validated predictor of mortality from community acquired pneumonia) to predict augmented levels of care and or death has been studied by the FLU-CIN in 1520 patients admitted to hospital with confirmed pandemic influenza A (H1N1)2009 [22].…”

“…Goodacre and colleagues (2010) conducted an evaluation of the discriminatory value of the CURB-65 score, PMEWS and CATs for predicting severe illness or mortality in patients with suspected pandemic influenza, but were unable to draw any conclusions regarding their clinical utility in a pandemic situation due to insufficient case numbers especially of adults, and a low incidence of severe outcome. [20] Semple, Myles, Van-Tam and other members of the UK Pandemic Influenza Clinical Information Network (FLU-CIN) characterised PCR-confirmed pandemic influenza disease in a much larger cohort of 1520 people (1040 adults, 480 children (age < 16 years)) admitted to hospital. [21] (Thorax submitted) FLU-CIN compared the clinical validity and utility of CATs, PMEWS and CURB-65 as predictors for interventions normally only available in hospital, higher levels of care, and death using area under the Receiver Operating Characteristic (ROC) curve (AUROC) comparisons with 95% confidence intervals (paper submitted).…”