Predicting poor outcome in patients with suspected COVID-19 presenting to the Emergency Department (COVERED) – Development, internal and external validation of a prediction model

Abstract

Background: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed. Objective: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome. Methods: In this prospective, multi-centre study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort. Results: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75). Conclusion: The COVERED risk score showed excellent discriminatory ability, also in external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.

Monocyte distribution width adds prognostic value in detection of COVID‐19 respiratory failure

“…3 Several risk scoring systems have been proposed as a result. 4,5 Many rely on routinely obtained laboratory data from cell count and population analyzers, with neutrophil-to-lymphocyte ratio (NLR) emerging as a leading predictor of COVID-19 disease severity. 6 The monocyte distribution width (MDW), another potential product of cell count analyzers, has been shown to be a reliable early marker of sepsis.…”

Can Peripheral Perfusion Index (PPI) Predict Disease Severity in COVID-19 Patients in the Emergency Department?

“…15 Premature recognition and early treatment of severe COVID-19 patients in the emergency services is important for emergency specialists. 16 However, making decisions in a limited time and recognizing major COVID-19 patients can be a difficult situation in emergency services. In some studies, PPI has been shown as a parameter that can be used in the triage field for patient acceptance and mortality predictor of major patients in emergency services.…”

Derivation and validation of a clinical decision rule to risk‐stratify COVID‐19 patients discharged from the emergency department: The CCEDRRN COVID discharge score

“…The CCEDRRN COVID discharge score has several advantages over other CDRs for use in the ED. 12 , 14 , 15 Our rule is simple and does not rely on the results of investigations or determination of patient comorbidities. The determination of comorbidities in the ED can be unreliable.…”

“…Several prior studies used longer intervals including 7, 13 , 16 14, 14 or even 30 days. 5 , 7 , 10 , 12 We felt that a rule predicting outcomes within 72 hours of ED assessment might convey a more appropriate assessment of immediate risks that might be mitigated with decisions made in the ED, specifically around the decision to admit at the index visit. The 72‐hour interval is commonly used as a health care quality metric for patient recidivism.…”

“…The CCEDRRN COVID discharge score uses an ultra‐short follow‐up period of 72 hours. Several prior studies used longer intervals including 7, 13,16 14, 14 or even 30 days 5,7,10,12 . We felt that a rule predicting outcomes within 72 hours of ED assessment might convey a more appropriate assessment of immediate risks that might be mitigated with decisions made in the ED, specifically around the decision to admit at the index visit.…”