Can we predict which COVID‐19 patients will need transfer to intensive care within 24 hours of floor admission?

Abstract

Background: Patients with COVID-19 can present to the emergency department (ED) at any point during the spectrum of illness, making it difficult to predict what level of care the patient will ultimately require. Admission to a ward bed, which is subsequently upgraded within hours to an intensive care unit (ICU) bed, represents an inability to appropriately predict the patient's course of illness. Predicting which patients will require ICU care within 24 hours would allow admissions to be managed more appropriately.Methods: This was a retrospective study of adults admitted to a large health care system, including 14 hospitals across the state of Indiana. Included patients were aged ≥ 18 years, were admitted to the hospital from the ED, and had a positive polymerase chain reaction (PCR) test for COVID-19. Patients directly admitted to the ICU or in whom the PCR test was obtained > 3 days after hospital admission were excluded.Extracted data points included demographics, comorbidities, ED vital signs, laboratory values, chest imaging results, and level of care on admission. The primary outcome was a combination of either death or transfer to ICU within 24 hours of admission to the hospital. Data analysis was performed by logistic regression modeling to determine a multivariable model of variables that could predict the primary outcome.Results: Of the 542 included patients, 46 (10%) required transfer to ICU within 24 hours of admission. The final composite model, adjusted for age and admission location, included history of heart failure and initial oxygen saturation of <93% plus either white blood cell count > 6.4 or glomerular filtration rate < 46. The odds ratio (OR) for decompensation within 24 hours was 5.17 (95% confidence interval [CI] = 2.17 to 12.31) when all criteria were present. For patients without the above criteria, the OR for ICU transfer was 0.20 (95% CI = 0.09 to 0.45).Conclusions: Although our model did not perform well enough to stand alone as a decision guide, it highlights certain clinical features that are associated with increased risk of decompensation.

Admission SpO2 and ROX index predict outcome in patients with COVID-19

“…The median (quartiles) of the CT score at ICU admission in the oxygen therapy group was 10 [ [7] , [8] , [9] , [10] , [11] , [12] ], which was significantly lower than that [18 [ [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] ]] in the MV group ( P < 0.0001). A significant negative correlation ( r = −0.6) was detected between SpO 2 on room air and the CT score ( P < 0.0001).…”

“…In the present study, we evaluated SpO 2 on the room air rather than on oxygen because the determination of FiO 2 remains inaccurate and influenced by minute ventilation, air leak, and breathing pattern in patients receiving oxygen through a facemask. Few studies had evaluated the validity of baseline SpO 2 as an important risk factor in COVID-10; however, most of these studies used SpO 2 as a component of multivariate prediction models [ [14] , [15] , [16] ] and did not use the need to ventilatory support as the primary outcome. Pre-hospital lowest SpO 2 had been evaluated for triaging of patients with COVID-19.…”

Outcomes for emergency department patients with suspected and confirmed COVID‐19: An analysis of the Australian experience in 2020 (COVED‐5)

“… 17 , 18 Specific severity rules have also been developed for ED populations, including the Quick COVID‐19 Severity Index and PRIEST score. 10 , 22 , 23 …”

“…A living systematic review has identified more than 100 prognostic models, 19 including the 4C mortality score and the QCOVID living risk prediction algorithm 17,18 . Specific severity rules have also been developed for ED populations, including the Quick COVID‐19 Severity Index and PRIEST score 10,22,23 …”

Re: Can we predict which COVID‐19 patients will need transfer to the intensive care within 24 hours of floor admission?

“…We were very interested to read the study by Wang et al 1 on predicting which ED patients with COVID‐19 will require escalation to intensive care unit within 24 hours of admission. They identified risk factors and developed triage models for the ED physician based on presenting history, signs, and symptoms.…”