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Prasad PA, Correia J, Fang MC, Fisher A, Correll M, Oreper S, Auerbach A. Performance of point-of-care severity scores to predict prognosis in patients admitted through the emergency department with COVID-19. J Hosp Med 2023; 18:413-423. [PMID: 37057912 PMCID: PMC11344580 DOI: 10.1002/jhm.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/14/2023] [Accepted: 03/31/2023] [Indexed: 04/15/2023]
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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Affiliation(s)
- Priya A. Prasad
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Jessica Correia
- HCA Healthcare, Sarah Cannon, USA, 1100 Dr. Martin L. King Jr. Blvd., Suite 800, Nashville, TN 37203
| | - Margaret C. Fang
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Arielle Fisher
- HCA Healthcare, Sarah Cannon, USA, 1100 Dr. Martin L. King Jr. Blvd., Suite 800, Nashville, TN 37203
| | - Mick Correll
- HCA Healthcare, Sarah Cannon, USA, 1100 Dr. Martin L. King Jr. Blvd., Suite 800, Nashville, TN 37203
| | - Sandra Oreper
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Andrew Auerbach
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA, USA
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Li N, Chu W. Development and validation of a survival prediction model in elder patients with community-acquired pneumonia: a MIMIC-population-based study. BMC Pulm Med 2023; 23:23. [PMID: 36650467 PMCID: PMC9847177 DOI: 10.1186/s12890-023-02314-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND To develop a prediction model predicting in-hospital mortality of elder patients with community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU). METHODS In this cohort study, data of 619 patients with CAP aged ≥ 65 years were obtained from the Medical Information Mart for Intensive Care III (MIMIC III) 2001-2012 database. To establish the robustness of predictor variables, the sample dataset was randomly partitioned into a training set group and a testing set group (ratio: 6.5:3.5). The predictive factors were evaluated using multivariable logistic regression, and then a prediction model was constructed. The prediction model was compared with the widely used assessments: Sequential Organ Failure Assessment (SOFA), Pneumonia Severity Index (PSI), systolic blood pressure, oxygenation, age and respiratory rate (SOAR), CURB-65 scores using positive predictive value (PPV), negative predictive value (NPV), accuracy (ACC), area under the curve (AUC) and 95% confidence interval (CI). The decision curve analysis (DCA) was used to assess the net benefit of the prediction model. Subgroup analysis based on the pathogen was developed. RESULTS Among 402 patients in the training set, 90 (24.63%) elderly CAP patients suffered from 30-day in-hospital mortality, with the median follow-up being 8 days. Hemoglobin/platelets ratio, age, respiratory rate, international normalized ratio, ventilation use, vasopressor use, red cell distribution width/blood urea nitrogen ratio, and Glasgow coma scales were identified as the predictive factors that affect the 30-day in-hospital mortality. The AUC values of the prediction model, the SOFA, SOAR, PSI and CURB-65 scores, were 0.751 (95% CI 0.749-0.752), 0.672 (95% CI 0.670-0.674), 0.607 (95% CI 0.605-0.609), 0.538 (95% CI 0.536-0.540), and 0.645 (95% CI 0.643-0.646), respectively. DCA result demonstrated that the prediction model could provide greater clinical net benefits to CAP patients admitted to the ICU. Concerning the pathogen, the prediction model also reported better predictive performance. CONCLUSION Our prediction model could predict the 30-day hospital mortality in elder patients with CAP and guide clinicians to identify the high-risk population.
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Affiliation(s)
- Na Li
- grid.449268.50000 0004 1797 3968Department of Clinical Medicine, College of Medicine, Pingdingshan University, Pingdingshan, 467000 People’s Republic of China
| | - Wenli Chu
- grid.508540.c0000 0004 4914 235XDepartment of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Xi’an Medical College, No. 167 Fangdong Street, Baqiao District, Xi’an, 710038 People’s Republic of China
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Vo-Pham-Minh T, Duong-Thi-Thanh V, Nguyen T, Phan-Tran-Xuan Q, Phan-Thi H, Bui-Anh T, Duong-Thien P, Duong-Quy S. The Impact of Risk Factors on Treatment Outcomes of Nosocomial Pneumonia Due to Gram-Negative Bacteria in the Intensive Care Unit. Pulm Ther 2021; 7:1-12. [PMID: 34652610 PMCID: PMC8517295 DOI: 10.1007/s41030-021-00175-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/24/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Nosocomial pneumonia is a common infection associated with high mortality in hospitalized patients. Nosocomial pneumonia, caused by gram-negative bacteria, often occurs in the elderly and patients with co-morbid diseases. Methods Original research using a prospective cross-sectional design was conducted on 281 patients in an intensive care unit setting with nosocomial pneumonia between July 2015 and July 2019. For each nosocomial pneumonia case, data regarding comorbidities, risk factors, patient characteristics, Charlson comorbidity index (CCI), Systemic Inflammatory Response Syndrome (SIRS), and quick Sepsis-Related Organ Failure Assessment (qSOFA) points and treatment outcomes were collected. Data were analyzed by SPSS 22.0. Results Nosocomial pneumonia due to gram-negative bacteria occurred in patients with neurological disorders (34.87%), heart diseases (16.37%), chronic renal failure (7.12%), and post-surgery (10.68%). Worse outcomes attributed to nosocomial pneumonia were high at 75.8%. Mechanical ventilation, change of antibiotics, and CCI ≥ 3 and qSOFA ≥ 2 were significantly negative prognostic factors (p < 0.05) on outcomes of nosocomial pneumonia. There was no difference in treatment effects between gender, age, time of onset pneumonia, SIRS score (p > 0.05). The pathogens were significant factors that influence treatment effects, but they weren't independent risk factors for poor outcomes (p = 0.823). Conclusions Patients with nosocomial pneumonia hospitalized in intensive care units are usually associated with many underlying diseases, including neurological diseases. Mechanical ventilation, a change in antibiotics, CCI ≥ 3, and qSOFA ≥ 2 are also associated with a worse prognosis of nosocomial pneumonia. CCI and qSOFA might be used in predicting the outcome of nosocomial pneumonia. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-021-00175-4.
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Affiliation(s)
- Thu Vo-Pham-Minh
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Van Duong-Thi-Thanh
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Thang Nguyen
- Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Quyen Phan-Tran-Xuan
- Department of General Medicine, Hospital Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Hoang Phan-Thi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS Australia
| | | | - Phuoc Duong-Thien
- Intensive Care Unit, Can Tho Central General Hospital, Can Tho, Vietnam
| | - Sy Duong-Quy
- Bio-Medical Research Centre, Lam Dong Medical College, 16 Ngo Quyen, Dalat, Vietnam.,Hershey Medical Center, Penn State Medical College, Hershey, PA USA
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Artero A, Madrazo M, Fernández-Garcés M, Muiño Miguez A, González García A, Crestelo Vieitez A, García Guijarro E, Fonseca Aizpuru EM, García Gómez M, Areses Manrique M, Martinez Cilleros C, Fidalgo Moreno MDP, Loureiro Amigo J, Gil Sánchez R, Rabadán Pejenaute E, Abella Vázquez L, Cañizares Navarro R, Solís Marquínez MN, Carrasco Sánchez FJ, González Moraleja J, Montero Rivas L, Escobar Sevilla J, Martín Escalante MD, Gómez-Huelgas R, Ramos-Rincón JM. Severity Scores in COVID-19 Pneumonia: a Multicenter, Retrospective, Cohort Study. J Gen Intern Med 2021; 36:1338-1345. [PMID: 33575909 PMCID: PMC7878165 DOI: 10.1007/s11606-021-06626-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Identification of patients on admission to hospital with coronavirus infectious disease 2019 (COVID-19) pneumonia who can develop poor outcomes has not yet been comprehensively assessed. OBJECTIVE To compare severity scores used for community-acquired pneumonia to identify high-risk patients with COVID-19 pneumonia. DESIGN PSI, CURB-65, qSOFA, and MuLBSTA, a new score for viral pneumonia, were calculated on admission to hospital to identify high-risk patients for in-hospital mortality, admission to an intensive care unit (ICU), or use of mechanical ventilation. Area under receiver operating characteristics curve (AUROC), sensitivity, and specificity for each score were determined and AUROC was compared among them. PARTICIPANTS Patients with COVID-19 pneumonia included in the SEMI-COVID-19 Network. KEY RESULTS We examined 10,238 patients with COVID-19. Mean age of patients was 66.6 years and 57.9% were males. The most common comorbidities were as follows: hypertension (49.2%), diabetes (18.8%), and chronic obstructive pulmonary disease (12.8%). Acute respiratory distress syndrome (34.7%) and acute kidney injury (13.9%) were the most common complications. In-hospital mortality was 20.9%. PSI and CURB-65 showed the highest AUROC (0.835 and 0.825, respectively). qSOFA and MuLBSTA had a lower AUROC (0.728 and 0.715, respectively). qSOFA was the most specific score (specificity 95.7%) albeit its sensitivity was only 26.2%. PSI had the highest sensitivity (84.1%) and a specificity of 72.2%. CONCLUSIONS PSI and CURB-65, specific severity scores for pneumonia, were better than qSOFA and MuLBSTA at predicting mortality in patients with COVID-19 pneumonia. Additionally, qSOFA, the simplest score to perform, was the most specific albeit the least sensitive.
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Affiliation(s)
- Arturo Artero
- Internal Medicine Department, Dr. Peset University Hospital, Universitat de València, Valencia, Spain
| | - Manuel Madrazo
- Internal Medicine Department, Dr. Peset University Hospital, Avda Gaspar Aguilar, n 90, postal code, 46017, Valencia, Spain.
| | - Mar Fernández-Garcés
- Internal Medicine Department, Dr. Peset University Hospital, Avda Gaspar Aguilar, n 90, postal code, 46017, Valencia, Spain
| | - Antonio Muiño Miguez
- Internal Medicine Department, Gregorio Marañon University Hospital, Madrid, Spain
| | | | | | - Elena García Guijarro
- Internal Medicine Department, Infanta Cristina University Hospital, Parla, Madrid, Spain
| | | | - Miriam García Gómez
- Internal Medicine Department, Urduliz Alfredo Espinosa Hospital, Urdúliz, Vizcaya, Spain
| | | | | | | | - José Loureiro Amigo
- Internal Medicine Department, Moisès Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | | | | | - Lucy Abella Vázquez
- Internal Medicine Department, Ntra Sra Candelaria University Hospital, Santa Cruz de Tenerife, Spain
| | - Ruth Cañizares Navarro
- Internal Medicine Department, San Juan de Alicante University Hospital, San Juan de Alicante, Alicante, Spain
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Iacorossi L, Fauci AJ, Napoletano A, D'Angelo D, Salomone K, Latina R, Coclite D, Iannone P. Triage protocol for allocation of critical health resources during Covid-19 pandemic and public health emergencies. A narrative review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020162. [PMID: 33525236 PMCID: PMC7927504 DOI: 10.23750/abm.v91i4.10393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/28/2020] [Indexed: 01/16/2023]
Abstract
Background and aim of the work. Triage during the Covid-19 pandemic can impose difficult allocation decisions when demand for mechanical ventilation or intensive care beds greatly exceeds available resources. Triage criteria should be objective, ethical, transparent, applied equitably and publically disclosed. The aim of this review is to describe the triage tools and process for critical care resources in a pandemic health emergency. Methods. A narrative review was conducted of the literature on five electronic databases, namely PubMed, CINHAL, Web of Science, Cochrane and Embase, searching for studies published from January 2006 to July 2020. Results. The results describe different triage tools. A gold standard of triage does not exist for the adult or paediatric population. Using probability of short-term survival as the sole allocation principle is problematic. In general, each triage protocol should be applied with a specific ethical justification, including transparency, duty to care, duty to steward resources, duty to plan, and distributive justice. Conclusions. Clinical triage decisions based on clinical judgment alone are prone to inconsistent application by triage officers in a pandemic. An ethical framework can inform decision-making and improve accountability. It remains difficult to connect clinical criteria and ethical criteria, because of the models on offer for health services. (www.actabiomedica.it)
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Affiliation(s)
- Laura Iacorossi
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Alice J Fauci
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Antonello Napoletano
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Daniela D'Angelo
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Katia Salomone
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | | | - Daniela Coclite
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Primiano Iannone
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
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Abstract
While the world is grappling with the consequences of a global pandemic related to SARS-CoV-2 causing severe pneumonia, available evidence points to bacterial infection with Streptococcus pneumoniae as the most common cause of severe community acquired pneumonia (SCAP). Rapid diagnostics and molecular testing have improved the identification of co-existent pathogens. However, mortality in patients admitted to ICU remains staggeringly high. The American Thoracic Society and Infectious Diseases Society of America have updated CAP guidelines to help streamline disease management. The common theme is use of timely, appropriate and adequate antibiotic coverage to decrease mortality and avoid drug resistance. Novel antibiotics have been studied for CAP and extend the choice of therapy, particularly for those who are intolerant of, or not responding to standard treatment, including those who harbor drug resistant pathogens. In this review, we focus on the risk factors, microbiology, site of care decisions and treatment of patients with SCAP.
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Affiliation(s)
- Girish B Nair
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - Michael S Niederman
- Weill Cornell Medical College, Pulmonary and Critical Care, New York Presbyterian/ Weill Cornell Medical Center, New York, NY, USA.
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