Identification on Admission of COVID-19 Patients at Risk of Subsequent Rapid Clinical Deterioration
Abstract
Introduction
Recent localized surges in COVID-19 cases have resulted in the hospitals serving those areas being overwhelmed. In such cases, the ability to rapidly and objectively determine a patient’s acuity and predict near-term care needs is a major challenge. At issue is the clinician’s ability to correctly identify patients at risk for subsequent rapid clinical deterioration. Data-driven tools that can support such determinations in real-time may be a valuable adjunct to clinician judgement during COVID-19 surges.
Objective
To assess the effectiveness of the Rothman Index (RI) predictive model in distinguishing the risk of subsequent deterioration or elevated care needs among hospitalized COVID-19 patients at the time of hospital admission.
Methods
We evaluated the initial RI score on admission to predict COVID-19 patient risk for 216 COVID-19 patients discharged from March 21stto June 7th, 2020 at Sinai LifeBridge Hospital and 1,453 COVID-19 patients discharged from any of Yale New Haven Health System’s Yale New Haven, Bridgeport, and Greenwich hospitals from April 1stto April 28th, 2020. In-hospital mortality as a function of age and RI on admission for COVID-19 and non-COVID-19 patients were compared. AUC values using each COVID-19 patient’s initial RI on admission to predict in-hospital mortality, mechanical ventilation, and ICU utilization were computed, as were precision and recall for mortality prediction at specific RI thresholds.
Results
The RI computed at the time of admission provides a high degree of objective discrimination to differentiate the COVID-19 population into high and low risk populations at the outset of hospitalization. The high risk segment based on initial RI constitutes 20-30% of the COVID-19 positive population with mortality rates from 40-50%. The low risk segment based on initial RI constitutes 40%-55% of the population with mortality rates ranging from 1%-8%. Of note is that COVID-19 patients who present with heightened but generally unremarkable acuity can be identified early as having considerably elevated risk for subsequent physiological deterioration.
Conclusion
COVID-19 patients exhibit elevated mortality rates compared to non-COVID-19 medical service patients and may be subject to rapid deterioration following hospital admission. A lack of predictive indicators for identifying patients at high risk of subsequent deterioration or death can pose a challenge to clinicians. The RI has excellent performance characteristics when stratifying risk among COVID-19 patients at the time of admission. The RI can assist clinicians in real-time with a high degree of objective discrimination by segmenting the COVID-19 population into high and low risk populations. This supports rapid and optimal patient bed assignment and resource allocation.
Related articles
Related articles are currently not available for this article.