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Thomas B, Goodacre S, Lee E, Sutton L, Bursnall M, Loban A, Waterhouse S, Simmonds R, Biggs K, Marincowitz C, Schutter J, Connelly S, Sheldon E, Hall J, Young E, Bentley A, Challen K, Fitzsimmons C, Harris T, Lecky F, Lee A, Maconochie I, Walter D. Prognostic accuracy of emergency department triage tools for adults with suspected COVID-19: the PRIEST observational cohort study. Emerg Med J 2021; 38:587-593. [PMID: 34083427 PMCID: PMC8182747 DOI: 10.1136/emermed-2020-210783] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The WHO and National Institute for Health and Care Excellence recommend various triage tools to assist decision-making for patients with suspected COVID-19. We aimed to compare the accuracy of triage tools for predicting severe illness in adults presenting to the ED with suspected COVID-19. METHODS We undertook a mixed prospective and retrospective observational cohort study in 70 EDs across the UK. We collected data from people attending with suspected COVID-19 and used presenting data to determine the results of assessment with the WHO algorithm, National Early Warning Score version 2 (NEWS2), CURB-65, CRB-65, Pandemic Modified Early Warning Score (PMEWS) and the swine flu adult hospital pathway (SFAHP). We used 30-day outcome data (death or receipt of respiratory, cardiovascular or renal support) to determine prognostic accuracy for adverse outcome. RESULTS We analysed data from 20 891 adults, of whom 4611 (22.1%) died or received organ support (primary outcome), with 2058 (9.9%) receiving organ support and 2553 (12.2%) dying without organ support (secondary outcomes). C-statistics for the primary outcome were: CURB-65 0.75; CRB-65 0.70; PMEWS 0.77; NEWS2 (score) 0.77; NEWS2 (rule) 0.69; SFAHP (6-point rule) 0.70; SFAHP (7-point rule) 0.68; WHO algorithm 0.61. All triage tools showed worse prediction for receipt of organ support and better prediction for death without organ support. At the recommended threshold, PMEWS and the WHO criteria showed good sensitivity (0.97 and 0.95, respectively) at the expense of specificity (0.30 and 0.27, respectively). The NEWS2 score showed similar sensitivity (0.96) and specificity (0.28) when a lower threshold than recommended was used. CONCLUSION CURB-65, PMEWS and the NEWS2 score provide good but not excellent prediction for adverse outcome in suspected COVID-19, and predicted death without organ support better than receipt of organ support. PMEWS, the WHO criteria and NEWS2 (using a lower threshold than usually recommended) provide good sensitivity at the expense of specificity. TRIAL REGISTRATION NUMBER ISRCTN56149622.
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Affiliation(s)
- Ben Thomas
- ScHARR, The University of Sheffield, Sheffield, UK
| | | | - Ellen Lee
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Laura Sutton
- ScHARR, The University of Sheffield, Sheffield, UK
| | | | - Amanda Loban
- ScHARR, The University of Sheffield, Sheffield, UK
| | | | | | - Katie Biggs
- ScHARR, The University of Sheffield, Sheffield, UK
| | | | | | | | | | - Jamie Hall
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Emma Young
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Andrew Bentley
- Acute intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kirsty Challen
- Emergency Department, Lancashire Teaching Hospitals NHS Foundation Trust, Chorley, UK
| | - Chris Fitzsimmons
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
- Emergency Department, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Fiona Lecky
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Andrew Lee
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Ian Maconochie
- Paediatric ED, Imperial College Healthcare NHS Trust, London, UK
| | - Darren Walter
- Emergency Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Goodacre S, Thomas B, Lee E, Sutton L, Loban A, Waterhouse S, Simmonds R, Biggs K, Marincowitz C, Schutter J, Connelly S, Sheldon E, Hall J, Young E, Bentley A, Challen K, Fitzsimmons C, Harris T, Lecky F, Lee A, Maconochie I, Walter D. Post-exertion oxygen saturation as a prognostic factor for adverse outcome in patients attending the emergency department with suspected COVID-19: a substudy of the PRIEST observational cohort study. Emerg Med J 2021; 38:88-93. [PMID: 33273040 PMCID: PMC7716294 DOI: 10.1136/emermed-2020-210528] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Measurement of post-exertion oxygen saturation has been proposed to assess illness severity in suspected COVID-19 infection. We aimed to determine the accuracy of post-exertional oxygen saturation for predicting adverse outcome in suspected COVID-19. METHODS We undertook a substudy of an observational cohort study across 70 emergency departments during the first wave of the COVID-19 pandemic in the UK. We collected data prospectively, using a standardised assessment form, and retrospectively, using hospital records, from patients with suspected COVID-19, and reviewed hospital records at 30 days for adverse outcome (death or receiving organ support). Patients with post-exertion oxygen saturation recorded were selected for this analysis. We constructed receiver-operating characteristic curves, calculated diagnostic parameters, and developed a multivariable model for predicting adverse outcome. RESULTS We analysed data from 817 patients with post-exertion oxygen saturation recorded after excluding 54 in whom measurement appeared unfeasible. The c-statistic for post-exertion change in oxygen saturation was 0.589 (95% CI 0.465 to 0.713), and the positive and negative likelihood ratios of a 3% or more desaturation were, respectively, 1.78 (1.25 to 2.53) and 0.67 (0.46 to 0.98). Multivariable analysis showed that post-exertion oxygen saturation was not a significant predictor of adverse outcome when baseline clinical assessment was taken into account (p=0.368). Secondary analysis excluding patients in whom post-exertion measurement appeared inappropriate resulted in a c-statistic of 0.699 (0.581 to 0.817), likelihood ratios of 1.98 (1.26 to 3.10) and 0.61 (0.35 to 1.07), and some evidence of additional prognostic value on multivariable analysis (p=0.019). CONCLUSIONS Post-exertion oxygen saturation provides modest prognostic information in the assessment of selected patients attending the emergency department with suspected COVID-19. TRIAL REGISTRATION NUMBER ISRCTN Registry (ISRCTN56149622) http://www.isrctn.com/ISRCTN28342533.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ben Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ellen Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Amanda Loban
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Richard Simmonds
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katie Biggs
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carl Marincowitz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - José Schutter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Connelly
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elena Sheldon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jamie Hall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Young
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Bentley
- Respiratory and Intensive Care Medicine, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Kirsty Challen
- Emergency Department, Lancashire Teaching Hospitals NHS Foundation Trust, Chorley, Lancashire, UK
| | - Chris Fitzsimmons
- Emergency Department, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Tim Harris
- Department of Emergency Medicine, Royal London Hospital, London, UK
| | - Fiona Lecky
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ian Maconochie
- Emergency Department, Imperial College Healthcare NHS Trust, London, UK
| | - Darren Walter
- Emergency Department, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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