Derivation and validation of a clinical severity score for acutely ill adults with suspected COVID-19: The PRIEST observational cohort study

  1. Steve Goodacre
  2. Ben Thomas
  3. Laura Sutton
  4. Matthew Burnsall
  5. Ellen Lee
  6. Mike Bradburn
  7. Amanda Loban
  8. Simon Waterhouse
  9. Richard Simmonds
  10. Katie Biggs
  11. Carl Marincowitz
  12. Jose Schutter
  13. Sarah Connelly
  14. Elena Sheldon
  15. Jamie Hall
  16. Emma Young
  17. Andrew Bentley
  18. Kirsty Challen
  19. Chris Fitzsimmons
  20. Tim Harris
  21. Fiona Lecky
  22. Andrew Lee
  23. Ian Maconochie
  24. Darren Walter

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Abstract

We aimed to derive and validate a triage tool, based on clinical assessment alone, for predicting adverse outcome in acutely ill adults with suspected COVID-19 infection.

Methods

We undertook a mixed prospective and retrospective observational cohort study in 70 emergency departments across the United Kingdom (UK). We collected presenting data from 22445 people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020. The primary outcome was death or organ support (respiratory, cardiovascular, or renal) by record review at 30 days. We split the cohort into derivation and validation sets, developed a clinical score based on the coefficients from multivariable analysis using the derivation set, and the estimated discriminant performance using the validation set.

Results

We analysed 11773 derivation and 9118 validation cases. Multivariable analysis identified that age, sex, respiratory rate, systolic blood pressure, oxygen saturation/inspired oxygen ratio, performance status, consciousness, history of renal impairment, and respiratory distress were retained in analyses restricted to the ten or fewer predictors. We used findings from multivariable analysis and clinical judgement to develop a score based on the NEWS2 score, age, sex, and performance status. This had a c-statistic of 0.80 (95% confidence interval 0.79–0.81) in the validation cohort and predicted adverse outcome with sensitivity 0.98 (0.97–0.98) and specificity 0.34 (0.34–0.35) for scores above four points.

Conclusion

A clinical score based on NEWS2, age, sex, and performance status predicts adverse outcome with good discrimination in adults with suspected COVID-19 and can be used to support decision-making in emergency care.

Registration

ISRCTN registry, ISRCTN28342533, http://www.isrctn.com/ISRCTN28342533

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  1. ScreenIT

    SciScore for 10.1101/2020.10.12.20209809: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementConsent: We did not seek consent to collect data but information about the study was provided in the ED and patients could withdraw their data at their request.
    IRB: Ethical approval: The North West - Haydock Research Ethics Committee gave a favourable opinion on the PAINTED study on 25 June 2012 (reference 12/NW/0303) and on the updated PRIEST study on 23rd March 2020.
    RandomizationAnalysis: We randomly split the study population into derivation and validation cohorts by randomly allocating the participating sites to one or other cohort.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Mortality prediction scores have an important role predicting mortality in hospital admissions but have limitations as triage tools. The inclusion of laboratory data as predictor variables usually requires hospital attendance, prolongs ED stay and prevents the rapid assessment required in ED or prehospital settings. Furthermore triage tools need to predict need for life-saving intervention rather than just mortality, and ideally need to be developed and evaluated in a relevant cohort, i.e. those with suspected COVID-19, including those not admitted to hospital after assessment. Rapid clinical scores have been proposed or evaluated in several studies. Liao et al [16] proposed adding age>65 years to the NEWS2 score to aid decision-making, based on early experience of the pandemic in China. Myrstad et al [17] reported a c-statistic of 0.822 (95% CI 0.690 to 0.953) for NEWS2 predicting death or severe disease in a small study (N=66) of people hospitalised with confirmed COVID-19. Hu et al [18] reported c-statistics of 0.833 (0.737 to 0.928) for the Rapid Emergency Medicine Score (REMS) and 0.677 (0.541 to 0.813) for the Modified Emergency Medicine Score (MEWS) for predicting mortality in critically ill patients with COVID-19. Haimovich et al [19] developed the quick COVID-19 severity index, consisting of respiratory rate, oxygen saturation, and oxygen flow rate, which predicted respiratory failure within 24 hours in adults admitted with COVID-19 requiring supplemental oxygen with...

    Results from TrialIdentifier: We found the following clinical trial numbers in your paper:

    IdentifierStatusTitle
    ISRCTN28342533NANA

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1371/journal.pone.0245840
  3. Version published to 10.1101/2020.10.12.20209809v2 on medRxiv
  4. Version published to 10.1101/2020.10.12.20209809v1 on medRxiv