Prognostic accuracy of emergency department triage tools for adults with suspected COVID-19: the PRIEST observational cohort study

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study

OBJECTIVE

To assess accuracy of telephone triage in identifying need for emergency care among those with suspected COVID-19 infection and identify factors which affect triage accuracy.

DESIGN

Observational cohort study.

SETTING

Community telephone triage provided in the UK by Yorkshire Ambulance Service NHS Trust (YAS).

PARTICIPANTS

40 261 adults who contacted National Health Service (NHS) 111 telephone triage services provided by YAS between 18 March 2020 and 29 June 2020 with symptoms indicating COVID-19 infection were linked to Office for National Statistics death registrations and healthcare data collected by NHS Digital.

OUTCOME

Accuracy of triage disposition was assessed in terms of death or need for organ support up to 30 days from first contact.

RESULTS

Callers had a 3% (1200/40 261) risk of serious adverse outcomes (death or organ support). Telephone triage recommended self-care or non-urgent assessment for 60% (24 335/40 261), with a 1.3% (310/24 335) risk of adverse outcomes. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (95% CI: 61% to 62%) for the primary outcome. Multivariable analysis suggested respiratory comorbidities may be overappreciated, and diabetes underappreciated as predictors of deterioration. Repeat contact with triage service appears to be an important under-recognised predictor of deterioration with 2 contacts (OR 1.77, 95% CI: 1.14 to 2.75) and 3 or more contacts (OR 4.02, 95% CI: 1.68 to 9.65) associated with false negative triage.

CONCLUSION

Patients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

Utility of ED triage tools in predicting the need for intensive respiratory or vasopressor support in adult patients with COVID-19

BACKGROUND

Serum and radiological parameters used to predict prognosis in COVID patients are not feasible in the Emergency Department. Due to its damaging effect on multiple organs and lungs, scores used to assess multiorgan damage and pneumonia such as Pandemic Medical Early Warning Score (PMEWS), National Early Warning Score 2 (NEWS2), WHO score, quick Sequential Organ Failure Assessment (qSOFA), and DS-CRB 65 can be used to triage patients in the Emergency Department. They can be used to predict patients with the highest risk of seven-day mortality and need for intensive respiratory or vasopressor support (IRVS).

PURPOSE

The primary purpose was to find the score with the highest AUC in predicting IRVS and mortality at seven days. Additional objective was to find out any independent factors associated with IRVS and mortality.

METHODS

The data of adult patients who presented to the Emergency Department (ED) between April 1, 2021 and June 30, 2021 were collected. The WHO score, CRB-65, DS-CRB 65, PMEWS, NEWS2, and qSOFA score were calculated for all patients. Statistical analysis was done and an ROC curve was calculated for all the tools for mortality and need for IRVS at seven days.

FINDINGS

677 patients presented to the Emergency Department with COVID-19 during the period above. Presence of Diabetes Mellitus (p = 0.001), Hypertension (p = 0.001), and chronic kidney disease(CKD) (p = 0.04) was significantly associated with need for IRVS. Age, duration of symptoms, pulse rate, respiratory rate, room air saturation, mental status at admission, and time to IRVS need were identified as independent predictors of in-hospital mortality. The longer the time to IRVS need from ED arrival, the higher the likelihood of mortality. PMEWS (0.830) had the highest AUC, followed by NEWS2 (0.805). A PMEWS cut-off of 6.5 was 74.2% sensitive and 78.3% specific in predicting the need for IRVS. ROC analysis to predict 7-day mortality showed that PMEWS had an AUC of 0.802 (0.766-0.839). QSOFA performed poorly in predicting IRVS (AUC 0.645) and 7-day mortality (AUC 0.677).

CONCLUSION

PMEWS may be used for triaging patients presenting to the Emergency Department with COVID-19 and accurately predicts the need for IRVS and seven day mortality.

Scoring systems for prediction of malaria and dengue fever in non-endemic areas among travellers arriving from tropical and subtropical areas

BACKGROUND

Fever is a common symptom among travellers returning from tropical/subtropical areas to Europe, and promptly distinguishing severe illnesses from self-limiting febrile syndromes is important but can be challenging due to non-specific clinical presentation.

METHODS

A cross-sectional study enrolled adults and children who sought care during 2015-2020 at Karolinska University Hospital, Stockholm, Sweden with fever within 2 months after returning from travel to a tropical/subtropical area. Data on symptoms and laboratory parameters were prospectively and retrospectively collected. Two separate scoring systems for malaria and dengue were developed based on backward elimination regressions.

RESULTS

In total, 2113 adults (18-94 years) and 202 children (1-17 years) were included, with 112 (4.8%) confirmed malaria by blood thick smear and 90 (3.9%) PCR/serology dengue-positive cases. Malaria was more likely in a patient who had visited sub-Saharan Africa and presented with combination of thrombocytopenia, anaemia and fever ≥39.5°C. Leucopenia, muscle pain and rash after travelling to Asia or South/Latin America indicated high probability of dengue. Two scoring systems with points between 0 and 7 for prediction of malaria or dengue were created based on the above predictors. Scores ≥3 indicated >80% sensitivity and specificity for malaria and >90% specificity for dengue in children and adults (area under the curve (AUC) for dengue: 0.92 in adults (95% CI 0.90 to 0.95) and 0.95 in children (95% CI 0.88 to 1.0); AUC for malaria: 0.93 in adults (95% CI 0.91 to 0.96) and 0.88 in children (95% CI 0.78 to 0.99)). Internal validation of optimism and overfitting was managed with bootstrap.

CONCLUSION

The presented scoring systems provide novel tools for structured assessment of patients with tropical fever in a non-endemic area and highlight clinical signs associated with a potential severe aetiology to direct the need for microbial investigation.

Prognostic accuracy of eight triage scores in suspected COVID-19 in an Emergency Department low-income setting: An observational cohort study

Introduction

Previous studies deriving and validating triage scores for patients with suspected COVID-19 in Emergency Department settings have been conducted in high- or middle-income settings. We assessed eight triage scores' accuracy for death or organ support in patients with suspected COVID-19 in Sudan.

Methods

We conducted an observational cohort study using Covid-19 registry data from eight emergency unit isolation centres in Khartoum State, Sudan. We assessed performance of eight triage scores including: PRIEST, LMIC-PRIEST, NEWS2, TEWS, the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS in suspected COVID-19. A composite primary outcome included death, ventilation or ICU admission.

Results

In total 874 (33.84 %, 95 % CI:32.04 % to 35.69 %) of 2,583 patients died, required intubation/non-invasive ventilation or HDU/ICU admission . All risk-stratification scores assessed had worse estimated discrimination in this setting, compared to studies conducted in higher-income settings: C-statistic range for primary outcome: 0.56-0.64. At previously recommended thresholds NEWS2, PRIEST and LMIC-PRIEST had high estimated sensitivities (≥0.95) for the primary outcome. However, the high baseline risk meant that low-risk patients identified at these thresholds still had a between 8 % and 17 % risk of death, ventilation or ICU admission.

Conclusion

None of the triage scores assessed demonstrated sufficient accuracy to be used clinically. This is likely due to differences in the health care system and population (23 % of patients died) compared to higher-income settings in which the scores were developed. Risk-stratification scores developed in this setting are needed to provide the necessary accuracy to aid triage of patients with suspected COVID-19.

Head-to-head comparison of six warning scores to predict mortality and clinical impairment in COVID-19 patients in emergency department

The aim was to evaluate the ability of six risk scores (4C, CURB65, SEIMC, mCHOSEN, QuickCSI, and NEWS2) to predict the outcome of patients with COVID-19 during the sixth pandemic wave in Spain. A retrospective observational study was performed to review the electronic medical records in patients ≥ 18 years of age who consulted consecutively in an emergency department with COVID-19 diagnosis throughout 2 months during the sixth pandemic wave. Clinical-epidemiological variables, comorbidities, and their respective outcomes, such as 30-day in-hospital mortality and clinical deterioration risk (a combined outcome considering: mechanical ventilation, intensive care unit admission, and/or 30-day in-hospital mortality), were calculated. The area under the curve for each risk score was calculated, and the resulting curves were compared by the Delong test, concluding with a decision curve analysis. A total of 626 patients (median age 79 years; 49.8% female) fulfilled the inclusion criteria. Two hundred and ninety-three patients (46.8%) had two or more comorbidities. Clinical deterioration risk criteria were present in 10.1% (63 cases), with a 30-day in-hospital mortality rate of 6.2% (39 cases). Comparison of the results showed that score 4C presented the best results for both outcome variables, with areas under the curve for mortality and clinical deterioration risk of 0.931 (95% CI 0.904-0.957) and 0.871 (95% CI 0.833-0.910) (both p < 0.001). The 4C Mortality Score proved to be the best score for predicting mortality or clinical deterioration risk among patients with COVID-19 attended in the emergency department in the following 30 days.

Association between the Neutrophil-to-Lymphocyte Ratio and Inpatient Mortality in Hospitalized Older Veterans with COVID-19 Infection

OBJECTIVES

Determine the association of high neutrophil-to-lymphocyte ratio (NLR) values with inpatient mortality and other outcomes in older veterans hospitalized with coronavirus disease 2019 (COVID-19).

METHODS

This was a retrospective, multicenter, cohort study of hospitalized adults, with laboratory-confirmed COVID-19 infection who were studied for 1 year after discharge or until death. The NLR was categorized into tertiles, and we determined frailty status with the 31-item Veterans Affairs Frailty Index. Multivariate logistic regression and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were performed to assess the association between NLR and clinical outcomes.

RESULTS

The study included 615 hospitalized adult veterans, mean age 66.12 (standard deviation 14.79) years, 93.82% (n = 577) male, 57.56% (n = 354) White, 81.0% (n = 498) non-Hispanic, median body mass index of 30.70 (interquartile range 25.64-34.99, standard deviation 7.13), and median length of stay of 8 days (interquartile range 3-15). Individuals in the middle and upper tertile groups had higher inpatient mortality (8.37%, n = 17 and 18.36%, n = 38, respectively) as compared with the lower tertile (2.93%, n = 6, P < 0.001). Compared with the lowest tertile, the middle and upper tertiles had a higher risk of inpatient mortality (aOR 3.75, 95% CI 1.38-10.21, P = 0.01, and aOR 8.13, 95% CI 3.18-20.84, P < 0.001, respectively). The highest tertile had a higher odds of intensive care unit admission (aOR 4.47, 95% CI 2.33-8.58, P < 0.001) and intensive care unit transfer (aOR 3.54, 95% CI 1.84-6.81, P < 0.001).

CONCLUSIONS

The NLR score is a clinically useful tool to predict in-hospital mortality in older patients with COVID-19.

Low CRB-65 Scores Effectively Rule out Adverse Clinical Outcomes in COVID-19 Irrespective of Chest Radiographic Abnormalities

Background: CRB-65 (Confusion; Respiratory rate ≥ 30/min; Blood pressure ≤ 90/60 mmHg; age ≥ 65 years) is a risk score for prognosticating patients with COVID-19 pneumonia. However, a significant proportion of COVID-19 patients have normal chest X-rays (CXRs). The influence of CXR abnormalities on the prognostic value of CRB-65 is unknown, limiting its wider applicability. Methods: We assessed the influence of CXR abnormalities on the prognostic value of CRB-65 in COVID-19. Results: In 589 study patients (71 years (IQR: 57-83); 57% males), 186 (32%) had normal CXRs. On ROC analysis, CRB-65 performed similarly in patients with normal vs. abnormal CXRs for predicting inpatient mortality (AUC 0.67 ± 0.05 vs. 0.69 ± 0.03). In patients with normal CXRs, a CRB-65 of 0 ruled out mortality, NIV requirement and critical illness (intubation and/or ICU admission) with negative predictive values (NPVs) of 94%, 98% and 99%, respectively. In patients with abnormal CXRs, a CRB-65 of 0 ruled out the same endpoints with NPVs of 91%, 83% and 86%, respectively. Patients with low CRB-65 scores had better inpatient survival than patients with high CRB-65 scores, irrespective of CXR abnormalities (all p < 0.05). Conclusions: CRB-65, CXR and CRP are independent predictors of mortality in COVID-19. Adding CXR findings (dichotomised to either normal or abnormal) to CRB-65 does not improve its prognostic accuracy. A low CRB-65 score of 0 may be a good rule-out test for adverse clinical outcomes in COVID-19 patients with normal or abnormal CXRs, which deserves prospective validation.

Validation of the qSOFA and CRB-65 in SARS-CoV-2-infected community-acquired pneumonia

Rationale

Prognostic accuracy of the quick sequential organ failure assessment (qSOFA) and CRB-65 (confusion, respiratory rate, blood pressure and age (≥65 years)) risk scores have not been widely evaluated in patients with SARS-CoV-2-positive compared to SARS-CoV-2-negative community-acquired pneumonia (CAP). The aim of the present study was to validate the qSOFA(-65) and CRB-65 scores in a large cohort of SARS-CoV-2-positive and SARS-CoV-2-negative CAP patients.

Methods

We included all cases with CAP hospitalised in 2020 from the German nationwide mandatory quality assurance programme and compared cases with SARS-CoV-2 infection to cases without. We excluded cases with unclear SARS-CoV-2 infection state, transferred to another hospital or on mechanical ventilation during admission. Predefined outcomes were hospital mortality and need for mechanical ventilation.

Results

Among 68 594 SARS-CoV-2-positive patients, hospital mortality (22.7%) and mechanical ventilation (14.9%) were significantly higher when compared to 167 880 SARS-CoV-2-negative patients (15.7% and 9.2%, respectively). All CRB-65 and qSOFA criteria were associated with both outcomes, and age dominated mortality prediction in SARS-CoV-2 (risk ratio >9). Scores including the age criterion had higher area under the curve (AUCs) for mortality in SARS-CoV-2-positive patients (e.g. CRB-65 AUC 0.76) compared to SARS-CoV-2 negative patients (AUC 0.68), and negative predictive value was highest for qSOFA-65=0 (98.2%). Sensitivity for mechanical ventilation prediction was poor with all scores (AUCs 0.59-0.62), and negative predictive values were insufficient (qSOFA-65=0 missed 1490 out of 10 198 patients (∼15%) with mechanical ventilation). Results were similar when excluding frail and palliative patients.

Conclusions

Hospital mortality and mechanical ventilation rates were higher in SARS-CoV-2-positive than SARS-CoV-2-negative CAP. For SARS-CoV-2-positive CAP, the CRB-65 and qSOFA-65 scores showed adequate prediction of mortality but not of mechanical ventilation.

The accuracy of the National Early Warning Score 2 in predicting early death in prehospital and emergency department settings: a systematic review and meta-analysis

Background

Many studies have explored the accuracy of the National Early Warning Score 2 (NEWS2) in predicting mortality in prehospital and emergency settings, but their findings are inconsistent. Whether NEWS2 is reliable for the pre-examination and triage of patients in prehospital settings and emergency departments remains debatable. Hence, this study aimed to evaluate the accuracy of NEWS2 in predicting mortality in prehospital settings and emergency departments.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wan Fang Data, Vip Database and SinoMed from the inception of each database to January 2023. The inclusion criteria: (I) patients in the prehospital settings or emergency departments; (II) the NEWS2 for predicting 2-day mortality, 30-day mortality, and in-hospital mortality; (III) sufficient data, such as sensitivity, specificity, overall survival, and deaths, were provided for the study; (IV) the type of study was accuracy prediction study. Two authors independently extracted data, including authors, year of publication, country of origin, study design, sample size, threshold cutoff values of NEWS2, and mortality. The PROBAST was used to assess the risk of bias in the included studies.

Results

Thirty studies with 185,835 participants were included. Among the 30 included studies, 13 have a high risk of bias, and 17 have a low risk of bias. The pooled sensitivity, specificity and AUC of 2-day mortality (early mortality), 30-day mortality and in-hospital mortality were 0.81 vs. 0.76 vs. 0.72 (95% CI: 0.61, 0.80), 0.81 vs. 0.69 vs. 0.78 (95% CI: 0.49, 0.93) and 0.88 vs. 0.80 vs. 0.78 (95% CI: 0.74, 0.82), respectively.

Conclusions

NEWS2 has excellent sensitivity and specificity in predicting early mortality in patients in the prehospitals setting and emergency departments. Nonetheless, it has poor performance in predicting in-hospital mortality and 30-day mortality. Our findings underpin the use of NEWS2 as a pre-examination and triage tool to predict early death in the prehospital settings and emergency departments. To improve the predictive accuracy, it should be used to monitor patients continuously rather than at a single point-in-time.

LMIC-PRIEST: Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19 in a middle-income setting

Background

Uneven vaccination and less resilient health care systems mean hospitals in LMICs are at risk of being overwhelmed during periods of increased COVID-19 infection. Risk-scores proposed for rapid triage of need for admission from the emergency department (ED) have been developed in higher-income settings during initial waves of the pandemic.

Methods

Routinely collected data for public hospitals in the Western Cape, South Africa from the 27 th August 2020 to 11 th March 2022 were used to derive a cohort of 446,084 ED patients with suspected COVID-19. The primary outcome was death or ICU admission at 30 days. The cohort was divided into derivation and Omicron variant validation sets. We developed the LMIC-PRIEST score based on the coefficients from multivariable analysis in the derivation cohort and existing triage practices. We externally validated accuracy in the Omicron period and a UK cohort.

Results

We analysed 305,564, derivation 140,520 Omicron and 12,610 UK validation cases. Over 100 events per predictor parameter were modelled. Multivariable analyses identified eight predictor variables retained across models. We used these findings and clinical judgement to develop a score based on South African Triage Early Warning Scores and also included age, sex, oxygen saturation, inspired oxygen, diabetes and heart disease. The LMIC-PRIEST score achieved C-statistics: 0.82 (95% CI: 0.82 to 0.83) development cohort; 0.79 (95% CI: 0.78 to 0.80) Omicron cohort; and 0.79 (95% CI: 0.79 to 0.80) UK cohort. Differences in prevalence of outcomes led to imperfect calibration in external validation. However, use of the score at thresholds of three or less would allow identification of very low-risk patients (NPV ≥0.99) who could be rapidly discharged using information collected at initial assessment.

Conclusion

The LMIC-PRIEST score shows good discrimination and high sensitivity at lower thresholds and can be used to rapidly identify low-risk patients in LMIC ED settings.

What is already known on this subject

Uneven vaccination in low- and middle-income countries (LMICs) coupled with less resilient health care provision mean that emergency health care systems in LMICs may still be at risk of being overwhelmed during periods of increased COVID-19 infection.Risk-stratification scores may help rapidly triage need for hospitalisation. However, those proposed for use in the ED for patients with suspected COVID-19 have been developed and validated in high-income settings.

What this study adds

The LMIC-PRIEST score has been robustly developed using a large routine dataset from the Western Cape, South Africa and is directly applicable to existing triage practices in LMICs.External validation across both income settings and COVID-19 variants showed good discrimination and high sensitivity (at lower thresholds) to a composite outcome indicating need for inpatient admission from the ED.

How this study might affect research practice or policy

Use of the LMIC-PRIEST score at thresholds of three or less would allow identification of very low-risk patients (negative predictive value ≥0.99) across all settings assessedDuring periods of increased demand, this could allow the rapid identification and discharge of patients from the ED using information collected at initial assessment.

Evaluation of the utility of NEWS2 during the COVID-19 pandemic

The emergence of the COVID-19 pandemic resulted in a dramatic increase in acutely ill patients presenting to hospitals with life-threatening acute respiratory disease. There was an immediate need for effective triage systems to facilitate clinical decision making. This review assesses the performance of the National Early Warning Score 2 (NEWS2) in two contexts. Firstly, the ability to detect acute illness severity and likely clinical deterioration in patients presenting to hospitals with COVID-19. Secondly, the use of NEWS2 in the longitudinal monitoring to detect acute clinical deterioration in hospitalised patients with COVID-19. NEWS2 appeared to be at least comparable and, often, superior to other scoring systems (such as qSOFA and CURB-65), and provided an earlier alert of deterioration. A NEWS2 of 5 had high short-term sensitivity within and was unlikely to miss patients with COVID-19 who go on to deteriorate, but this comes with moderate specificity. However, the specificity of these systems is likely underestimated because preventing deterioration is their purpose. NEWS2 is an adjunct to clinical decision making and has served that purpose during the COVID-19 pandemic, playing an important role in communicating illness severity, clinical deterioration, triaging patients to appropriate levels of care and prompting completion of treatment escalation plans for those with high scores and at imminent risk of deterioration.

Physiologic Scoring Systems in Predicting the COVID-19 Patients' one-month Mortality; a Prognostic Accuracy Study

Introduction : It is critical to quickly and easily identify severe coronavirus disease 2019 (COVID-19) patients and predict their mortality. This study aimed to determine the accuracy of the physiologic scoring systems in predicting the mortality of COVID-19 patients. Methods: This prospective cross-sectional study was performed on COVID-19 patients admitted to the emergency department (ED). The clinical characteristics of the participants were collected by the emergency physicians and the accuracy of the Quick Sequential Failure Assessment (qSOFA), Coronavirus Clinical Characterization Consortium (4C) Mortality, National Early Warning Score-2 (NEWS2), and Pandemic Respiratory Infection Emergency System Triage (PRIEST) scores for mortality prediction was evaluated. Results: Nine hundred and twenty-one subjects were included. Of whom, 745 (80.9%) patients survived after 30 days of admission. The mean age of patients was 59.13 ± 17.52 years, and 550 (61.6%) subjects were male. Non-Survived patients were significantly older (66.02 ± 17.80 vs. 57.45 ± 17.07, P< 0.001) and had more comorbidities (diabetes mellitus, respiratory, cardiovascular, and cerebrovascular disease) in comparison with survived patients. For COVID-19 mortality prediction, the AUROCs of PRIEST, qSOFA, NEWS2, and 4C Mortality score were 0.846 (95% CI [0.821-0.868]), 0.788 (95% CI [0.760-0.814]), 0.843 (95% CI [0.818-0.866]), and 0.804 (95% CI [0.776-0.829]), respectively. All scores were good predictors of COVID-19 mortality. Conclusion: All studied physiologic scores were good predictors of COVID-19 mortality and could be a useful screening tool for identifying high-risk patients. The NEWS2 and PRIEST scores predicted mortality in COVID-19 patients significantly better than qSOFA.

Accuracy of emergency medical service telephone triage of need for an ambulance response in suspected COVID-19: an observational cohort study

OBJECTIVE

To assess accuracy of emergency medical service (EMS) telephone triage in identifying patients who need an EMS response and identify factors which affect triage accuracy.

DESIGN

Observational cohort study.

SETTING

Emergency telephone triage provided by Yorkshire Ambulance Service (YAS) National Health Service (NHS) Trust.

PARTICIPANTS

12 653 adults who contacted EMS telephone triage services provided by YAS between 2 April 2020 and 29 June 2020 assessed by COVID-19 telephone triage pathways were included.

OUTCOME

Accuracy of call handler decision to dispatch an ambulance was assessed in terms of death or need for organ support at 30 days from first contact with the telephone triage service.

RESULTS

Callers contacting EMS dispatch services had an 11.1% (1405/12 653) risk of death or needing organ support. In total, 2000/12 653 (16%) of callers did not receive an emergency response and they had a 70/2000 (3.5%) risk of death or organ support. Ambulances were dispatched to 4230 callers (33.4%) who were not conveyed to hospital and did not deteriorate. Multivariable modelling found variables of older age (1 year increase, OR: 1.05, 95% CI: 1.04 to 1.05) and presence of pre-existing respiratory disease (OR: 1.35, 95% CI: 1.13 to 1.60) to be predictors of false positive triage.

CONCLUSION

Telephone triage can reduce ambulance responses but, with low specificity. A small but significant proportion of patients who do not receive an initial emergency response deteriorated. Research to improve accuracy of EMS telephone triage is needed and, due to limitations of routinely collected data, this is likely to require prospective data collection.

Comparing complaint-based triage scales and early warning scores for emergency department triage

Background

Emergency triage systems are used globally to prioritise care based on patients’ needs. These systems are commonly based on patient complaints, while the need for timely interventions on regular hospital wards is usually assessed with early warning scores (EWS). We aim to directly compare the ability of currently used triage scales and EWS scores to recognise patients in need of urgent care in the ED.

Methods

We performed a retrospective, single-centre study on all patients who presented to the ED of a Dutch Level 1 trauma centre, between 1 September 2018 and 24 June 2020 and for whom a Netherlands Triage System (NTS) score as well as a Modified Early Warning Score (MEWS) was recorded. The performance of these scores was assessed using surrogate markers for true urgency and presented using bar charts, cross tables and a paired area under the curve (AUC).

Results

We identified 12 317 unique patient visits where NTS and MEWS scores were documented during triage. A paired comparison of the AUC of these scores showed that the MEWS score had a significantly better AUC than the NTS for predicting the need for hospital admission (0.65 vs 0.60; p<0.001) or 30-day all-cause mortality (0.70 vs 0.60; p<0.001). Furthermore, when non-urgent MEWS scores co-occur with urgent NTS scores, the MEWS score seems to more accurately capture the urgency level that is warranted.

Conclusions

The results of this study suggest that EWSs could potentially be used to replace the current emergency triage systems.

Composite Outcomes in Clinical Prediction Modeling: Are We Trying to Predict Apples and Oranges?

Composite outcomes are widely used in clinical research. Existing literature has considered the pros and cons of composite outcomes in clinical trials, but their extensive use in clinical prediction has received much less attention. Clinical prediction assists decision-making by directing patients with higher risks of adverse outcomes toward interventions that provide the greatest benefits to those at the greatest risk. In this article, we summarize our existing understanding of the advantages and disadvantages of composite outcomes, consider how these relate to clinical prediction, and highlight the problem of key predictors having markedly different associations with individual components of the composite outcome. We suggest that a "composite outcome fallacy" may occur when a clinical prediction model is based on strong associations between key predictors and one component of a composite outcome (such as mortality) and used to direct patients toward intervention when these predictors actually have an inverse association with a more relevant component of the composite outcome (such as the use of a lifesaving intervention). We propose that clinical prediction scores using composite outcomes should report their accuracy for key components of the composite outcome and examine for inconsistencies among predictor variables.

Prognostic value of National Early Warning Scores (NEWS2) and component physiology in hospitalised patients with COVID-19: a multicentre study

Background

National Early Warning Scores (NEWS2) are used to detect all-cause deterioration. While studies have looked at NEWS2, the use of virtual consultation and remote monitoring of patients with COVID-19 mean there is a need to know which physiological observations are important.

Aim

To investigate the relationship between outcome and NEWS2, change in NEWS2 and component physiology in COVID-19 inpatients.

Methods

A multi-centre retrospective study of electronically recorded, routinely collected physiological measurements between March and June 2020. First and maximum NEWS2, component scores and outcomes were recorded. Areas under the curve (AUCs) for 2-day, 7-day and 30-day mortality were calculated.

Results

Of 1263 patients, 26% died, 7% were admitted to intensive care units (ICUs) before discharge and 67% were discharged without ICU. Of 1071 patients with initial NEWS2, most values were low: 50% NEWS2=0–2, 27% NEWS2=3–4, 14% NEWS2=5–6 and 9% NEWS2=7+. Maximum scores were: 14% NEWS2=0–2, 22% NEWS2=3–4, 17% NEWS2=5–6 and 47% NEWS2=7+. Higher first and maximum scores were predictive of mortality, ICU admission and longer length of stay. AUCs based on 2-day, 7-day, 30-day and any hospital mortality were 0.77 (95% CI 0.70 to 0.84), 0.70 (0.65 to 0.74), 0.65 (0.61 to 0.68) and 0.65 (0.61 to 0.68), respectively. The AUCs for 2-day mortality were 0.71 (0.65 to 0.77) for supplemental oxygen, 0.65 (0.56 to 0.73) oxygen saturation and 0.64 (0.56 to 0.73) respiratory rate.

Conclusion

While respiratory parameters were most predictive, no individual parameter was as good as a full NEWS2, which is an acceptable predictor of short-term mortality in patients with COVID-19. This supports recommendation to use NEWS2 alongside clinical judgement to assess patients with COVID-19.

Prognostic accuracy of triage tools for adults with suspected COVID-19 in a prehospital setting: an observational cohort study

Background

Tools proposed to triage patient acuity in COVID-19 infection have only been validated in hospital populations. We estimated the accuracy of five risk-stratification tools recommended to predict severe illness and compared accuracy to existing clinical decision making in a prehospital setting.

Methods

An observational cohort study using linked ambulance service data for patients attended by Emergency Medical Service (EMS) crews in the Yorkshire and Humber region of England between 26 March 2020 and 25 June 2020 was conducted to assess performance of the Pandemic Respiratory Infection Emergency System Triage (PRIEST) tool, National Early Warning Score (NEWS2), WHO algorithm, CRB-65 and Pandemic Medical Early Warning Score (PMEWS) in patients with suspected COVID-19 infection. The primary outcome was death or need for organ support.

Results

Of the 7549 patients in our cohort, 17.6% (95% CI 16.8% to 18.5%) experienced the primary outcome. The NEWS2 (National Early Warning Score, version 2), PMEWS, PRIEST tool and WHO algorithm identified patients at risk of adverse outcomes with a high sensitivity (>0.95) and specificity ranging from 0.3 (NEWS2) to 0.41 (PRIEST tool). The high sensitivity of NEWS2 and PMEWS was achieved by using lower thresholds than previously recommended. On index assessment, 65% of patients were transported to hospital and EMS decision to transfer patients achieved a sensitivity of 0.84 (95% CI 0.83 to 0.85) and specificity of 0.39 (95% CI 0.39 to 0.40).

Conclusion

Use of NEWS2, PMEWS, PRIEST tool and WHO algorithm could improve sensitivity of EMS triage of patients with suspected COVID-19 infection. Use of the PRIEST tool would improve sensitivity of triage without increasing the number of patients conveyed to hospital.

Development and Validation of the Acute PNeumonia Early Assessment Score for Safely Discharging Low-Risk SARS-CoV-2-Infected Patients from the Emergency Department

A continuous demand for assistance and an overcrowded emergency department (ED) require early and safe discharge of low-risk severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients. We developed (n = 128) and validated (n = 330) the acute PNeumonia early assessment (aPNea) score in a tertiary hospital and preliminarily tested the score on an external secondary hospital (n = 97). The score's performance was compared to that of the National Early Warning Score 2 (NEWS2). The composite outcome of either death or oral intubation within 30 days from admission occurred in 101 and 28 patients in the two hospitals, respectively. The area under the receiver operating characteristic (AUROC) curve of the aPNea model was 0.86 (95% confidence interval (CI), 0.78-0.93) and 0.79 (95% CI, 0.73-0.89) for the development and validation cohorts, respectively. The aPNea score discriminated low-risk patients better than NEWS2 at a 10% outcome probability, corresponding to five cut-off points and one cut-off point, respectively. aPNea's cut-off reduced the number of unnecessary hospitalizations without missing outcomes by 27% (95% CI, 9-41) in the validation cohort. NEWS2 was not significant. In the external cohort, aPNea's cut-off had 93% sensitivity (95% CI, 83-102) and a 94% negative predictive value (95% CI, 87-102). In conclusion, the aPNea score appears to be appropriate for discharging low-risk SARS-CoV-2-infected patients from the ED.

Palliative care in COVID-19

PURPOSE OF REVIEW

The purpose of this paper is (1) to provide insight in the palliative care needs of patients with COVID-19; (2) to highlight the challenges of COVID-19 for palliative care; and (3) to highlight developments in COVID-19 palliative care.

RECENT FINDINGS

Patients with serious COVID-19 have palliative care needs in all domains: physical, psychological, social and spiritual. COVID-19 palliative care is confronted with many challenges, including: the uncertain prognosis, resource limitations, challenges regarding advance care planning, lack of guidance, limited multidisciplinary collaboration, need for remote communication, restrictions in family visits, and burden for clinicians. Palliative care responded with many developments: development of services; integration of palliative care with other services; tools to support advance care planning, (remote) communication with patients and families, or spiritual care; and care for team members.

SUMMARY

Palliative care has an important role in this pandemic. Palliative care rapidly developed services and opportunities were found to support patients, families and clinicians. Further developments are warranted to face future demands of a pandemic, including integrated palliative care and education in palliative care skills across all specialties. Intervention studies are needed to enable evidence-based recommendations for palliative care in COVID-19.