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. 2023 May;18(5):413-423.
doi: 10.1002/jhm.13106. Epub 2023 Apr 14.

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19

Priya A Prasad  1 , Jessica Correia  2 , Margaret C Fang  1 , Arielle Fisher  2 , Mick Correll  2 , Sandra Oreper  1 , Andrew Auerbach  1
Affiliations

Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19

Priya A Prasad et al. J Hosp Med. 2023 May.

Abstract

Background: Identifying COVID-19 patients at the highest risk of poor outcomes is critical in emergency department (ED) presentation. Sepsis risk stratification scores can be calculated quickly for COVID-19 patients but have not been evaluated in a large cohort.

Objective: To determine whether well-known risk scores can predict poor outcomes among hospitalized COVID-19 patients.

Designs, settings, and participants: A retrospective cohort study of adults presenting with COVID-19 to 156 Hospital Corporation of America (HCA) Healthcare EDs, March 2, 2020, to February 11, 2021.

Intervention: Quick Sequential Organ Failure Assessment (qSOFA), Shock Index, National Early Warning System-2 (NEWS2), and quick COVID-19 Severity Index (qCSI) at presentation.

Main outcome and measures: The primary outcome was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) admission, mechanical ventilation, and vasopressors receipt. Patients scored positive with qSOFA ≥ 2, Shock Index > 0.7, NEWS2 ≥ 5, and qCSI ≥ 4. Test characteristics and area under the receiver operating characteristics curves (AUROCs) were calculated.

Results: We identified 90,376 patients with community-acquired COVID-19 (mean age 64.3 years, 46.8% female). 17.2% of patients died in-hospital, 28.6% went to the ICU, 13.7% received mechanical ventilation, and 13.6% received vasopressors. There were 3.8% qSOFA-positive, 45.1% Shock Index-positive, 49.8% NEWS2-positive, and 37.6% qCSI-positive at ED-triage. NEWS2 exhibited the highest AUROC for in-hospital mortality (0.593, confidence interval [CI]: 0.588-0.597), ICU admission (0.602, CI: 0.599-0.606), mechanical ventilation (0.614, CI: 0.610-0.619), and vasopressor receipt (0.600, CI: 0.595-0.604).

Conclusions: Sepsis severity scores at presentation have low discriminative power to predict outcomes in COVID-19 patients and are not reliable for clinical use. Severity scores should be developed using features that accurately predict poor outcomes among COVID-19 patients to develop more effective risk-based triage.

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Conflict of interest statement

Dr. Prasad and Ms. Oreper report personal fees from EpiExcellence, LLC outside the submitted work. Dr. Fang’s institution received funding from the National Heart, Lung, and Blood Institute (NHLBI) K24HL141354 and Patient-Centered Outcomes Research Institute. Dr. Auerbach’s institution received funding from the Agency on Healthcare Research and Quality (AHRQ) R01HS027369 and the Moore Foundation Grant 8856. He is also a founder of ADVICE Health, which has no relationship to this work.

Figures

Figure 1.
Figure 1.
Receiver Operator Characteristic Curves for qSOFA, Shock Index, NEWS2, and qCSI, considering the full range of possible scores measured in the cohort. The curves display the discrimination of each score to predict (a) in-hospital mortality, (b) admission to the intensive care unit (c) need for mechanical ventilation, and (d) need for vasopressors. The area under the receiver operator characteristic curves (AUROC) and 95% confidence intervals are included.
Figure 1.
Figure 1.
Receiver Operator Characteristic Curves for qSOFA, Shock Index, NEWS2, and qCSI, considering the full range of possible scores measured in the cohort. The curves display the discrimination of each score to predict (a) in-hospital mortality, (b) admission to the intensive care unit (c) need for mechanical ventilation, and (d) need for vasopressors. The area under the receiver operator characteristic curves (AUROC) and 95% confidence intervals are included.
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