Letter to the Editor: Discussion of the Article “Prognostic Accuracy of the SIRS, qSOFA, and NEWS for Early Detection of Clinical Deterioration in SARS-CoV-2 Infected Patients”

Abstract

We read with interest the article by Dr. Jang and colleagues 1 on the ability of disease severity scores to predict more rapid clinical deterioration in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infected patients. Of the three scoring systems analyzed, the National Early Warning Score (NEWS) measured at the time of hospital admission was best able to predict critical outcome, defined in this study as admission to the intensive care unit (ICU) or death, with critically ill patients defined similarly. We believe that these definitions should be modified.These definitions of critical outcome and critically ill patients would result in a target group with heterogeneous characteristics, including not only patients with severe coronavirus disease 2019 (COVID-19) but patients with other conditions. The outbreak of COVID-19 may result in a selection bias, as some critically ill patients may not be admitted to the ICU because of a shortage of ICU beds. Actually, some critical patients using high flow oxygen were in the general ward, and some elderly patients who died from conditions other than COVID-19 were not actively treated and had do-not-resuscitate (DNR) orders.In addition, these definitions of critical outcomes and critically ill patients do not include timing. Admission to the ICU care and death was assumed to occur within 28 days after initial hospitalization because 28-day mortality rates were measured. In another study evaluating the National Early Warning Score 2 (NEWS2) in 3,869 patients, the primary outcome was defined as patient status 14 days after symptom onset, with patients categorized as those who were transferred to the ICU or died (WHO-COVID-19 Outcomes Scale scores of 6-8) and those who were not transferred and did not die (scores of 3-5) within a specific time after symptom onset. 2 Third, the definitions of critical outcomes and critically ill patients cited by Jang et al. were too broad. We found it unusual that the definition of critical outcome did not include acute respiratory distress syndrome or respiratory failure. A study showing an association between hypoxemia and mortality in 140 COVID-19 patients defined disease severity according to

NEWS2 and laboratory predictors correlated with clinical deterioration in hospitalised patients with COVID-19

“…However, they reported the results of only 17 elderly patients. Kim et al showed that NEWS2 scores on D0 significantly differed in non-critical and critical patients (2.6 ± 2.6 vs. 8.2 ± 3.3, p<0.001) (9). In the study of Volff et al, the AUC value of NEWS score to predict ICU admisson or death was 0.74, in consistent with our result.…”