Dataset Information

The CCEDRRN COVID-19 Mortality Score to predict death among nonpalliative patients with COVID-19 presenting to emergency departments: a derivation and validation study.

ABSTRACT:

Background

Predicting mortality from COVID-19 using information available when patients present to the emergency department can inform goals-of-care decisions and assist with ethical allocation of critical care resources. The study objective was to develop and validate a clinical score to predict emergency department and in-hospital mortality among consecutive nonpalliative patients with COVID-19; in this study, we define palliative patients as those who do not want resuscitative measures, such as intubation, intensive care unit care or cardiopulmonary resuscitation.

Methods

This derivation and validation study used observational cohort data recruited from 46 hospitals in 8 Canadian provinces participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). We included adult (age ≥ 18 yr) nonpalliative patients with confirmed COVID-19 who presented to the emergency department of a participating site between Mar. 1, 2020, and Jan. 31, 2021. We randomly assigned hospitals to derivation or validation, and prespecified clinical variables as candidate predictors. We used logistic regression to develop the score in a derivation cohort and examined its performance in predicting emergency department and in-hospital mortality in a validation cohort.

Results

Of 8761 eligible patients, 618 (7.0%) died. The CCEDRRN COVID-19 Mortality Score included age, sex, type of residence, arrival mode, chest pain, severe liver disease, respiratory rate and level of respiratory support. The area under the curve was 0.92 (95% confidence interval [CI] 0.90-0.93) in derivation and 0.92 (95% CI 0.90-0.93) in validation. The score had excellent calibration. These results suggest that scores of 6 or less would categorize patients as being at low risk for in-hospital death, with a negative predictive value of 99.9%. Patients in the low-risk group had an in-hospital mortality rate of 0.1%. Patients with a score of 15 or higher had an observed mortality rate of 81.0%.

Interpretation

The CCEDRRN COVID-19 Mortality Score is a simple score that can be used for level-of-care discussions with patients and in situations of critical care resource constraints to accurately predict death using variables available on emergency department arrival. The score was derived and validated mostly in unvaccinated patients, and before variants of concern were circulating widely and newer treatment regimens implemented in Canada.

Study registration

ClinicalTrials.gov, no. NCT04702945.

SUBMITTER: Hohl CM

PROVIDER: S-EPMC9259439 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:BackgroundTreatment for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care utilization, and outcomes of COVID-19 patients presenting to emergency departments (ED) across pandemic waves.MethodsThis observational study enrolled consecutive eligible COVID-19 patients presenting to 46 EDs participating in the Canadian COVID-19 ED Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. Secondary outcomes included treatments, hospital and ICU admissions, ED revisits and readmissions. Logistic regression modeling assessed the impact of pandemic wave on outcomes.ResultsWe enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the ED. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 7.4; 95% confidence interval [CI] 6.2-8.9), and invasive mechanical ventilation decreased (OR 0.5; 95% CI 0.4-0.7) in the second wave compared to the first. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95% CI 0.6-0.8) and critical care admission (OR 0.7; 95% CI 0.6-0.9) decreased, while mortality remained unchanged (OR 0.7; 95% CI 0.5-1.1).InterpretationIn patients presenting to cute care facilities, we observed rapid uptake of evidence-based therapies and less use of experimental therapies in the second wave. We observed increased rates of ED discharges and lower hospital and critical care resource use over time. Substantial reductions in mechanical ventilation were not associated with increasing mortality. Advances in treatment strategies created health system efficiencies without compromising patient outcomes.Trial registrationClinicaltrials.gov, NCT04702945.

Project description:ObjectivesTo develop and validate a clinical risk score that can accurately quantify the probability of SARS-CoV-2 infection in patients presenting to an emergency department without the need for laboratory testing.DesignCohort study of participants in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) registry. Regression models were fitted to predict a positive SARS-CoV-2 test result using clinical and demographic predictors, as well as an indicator of local SARS-CoV-2 incidence.Setting32 emergency departments in eight Canadian provinces.Participants27 665 consecutively enrolled patients who were tested for SARS-CoV-2 in participating emergency departments between 1 March and 30 October 2020.Main outcome measuresPositive SARS-CoV-2 nucleic acid test result within 14 days of an index emergency department encounter for suspected COVID-19 disease.ResultsWe derived a 10-item CCEDRRN COVID-19 Infection Score using data from 21 743 patients. This score included variables from history and physical examination and an indicator of local disease incidence. The score had a c-statistic of 0.838 with excellent calibration. We externally validated the rule in 5295 patients. The score maintained excellent discrimination and calibration and had superior performance compared with another previously published risk score. Score cut-offs were identified that can rule-in or rule-out SARS-CoV-2 infection without the need for nucleic acid testing with 97.4% sensitivity (95% CI 96.4 to 98.3) and 95.9% specificity (95% CI 95.5 to 96.0).ConclusionsThe CCEDRRN COVID-19 Infection Score uses clinical characteristics and publicly available indicators of disease incidence to quantify a patient's probability of SARS-CoV-2 infection. The score can identify patients at sufficiently high risk of SARS-CoV-2 infection to warrant isolation and empirical therapy prior to test confirmation while also identifying patients at sufficiently low risk of infection that they may not need testing.Trial registration numberNCT04702945.

Project description:IntroductionDuring the emergence of the SARS-CoV-2 (COVID-19) pandemic, there were substantial changes in United States (U.S.) emergency department (ED) volumes and acuity of patient presentation compared to more recent years. Thus, the purpose of this study was to characterize the incidence of specific upper extremity (UE) injuries presenting to U.S. EDs during the COVID-19 pandemic and analyze trends across age groups and rates of hospital admission compared to years prior.MethodsThe National Electronic Injury Surveillance System (NEISS) database was queried to identify patients who presented to U.S. EDs for an UE orthopaedic injury between 2016 and 2020. Chi-square analysis and logistic regression were used to assess for differences in ED presentation volume and hospital admissions between pre-pandemic (2016 through 2019) and during-pandemic (2020) times.ResultsThese queries returned 285,583 cases, representing a total estimate of 10,452,166 injuries presenting to EDs across the U.S. The mean incidence of UE orthopaedic injuries was 640.2 (95% CI, 638.2-642.3) injuries per 100,000 person-years, with the greatest year to year decrease in incidence occurring between 2019 and 2020 (20.1%). The largest number of estimated admissions occurred in 2020, with a total 135,018 admissions (95% CI, 131,518-138,517), a 41.6% increase from the average number of admissions between 2016 and 2019.ConclusionThere was a 20.1% decrease in the incidence of UE orthopaedic injuries presenting to EDs after the start of the COVID-19 pandemic with a concomitant 41.2% increase in the number of hospital admissions from the ED in 2020 compared to recent pre-pandemic years. We speculate that at least some elective, semi-elective or urgent ambulatory surgeries were canceled or delayed due to the pandemic and were subsequently directed to the ED for admission. Regardless of the cause of increased UE orthopaedic admissions, policy planners and administrators should be aware of the additional stresses placed on already burdened ED and inpatient services.Level of evidenceLevel III - Retrospective Cohort Study.