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Three Part Question

[In adults with confirmed or suspected COVID-19 infection attending the Emergency Department], are [risk stratification or decision models available] to [predict the requirement for admission and subsequent hospital care]?

Clinical Scenario

One month after social distancing measures were introduced in the UK, a 35 year-old man attends with shortness of breath and is streamed to be seen by you in your COVID-19 assessment area. He has been isolating at home for the last three days after developing myalgia and a fever. He is normally fit and well and has not been tested for COVID-19. His oxygen saturations are 93% at rest on air and his respiratory rate is 22 breaths per minute. You consult the NHS England guidance which advises that the decision to admit or discharge should be based on a senior clinical assessment. You wonder if a model is available to guide this decision.

Search Strategy

On 17 Apr 2020, Pubmed and EMBASE databases searched (via HDAS)
Title and Abstract: (covid OR coronavirus OR SARS-CoV-2) AND (prognos* OR score OR decision OR predic*)

Search Outcome

Pubmed 451 + EMBASE 290 results published since 01 Jan 2019. 118 titles selected for abstract review, 76 selected for full text review. 1 systematic review was identified relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wynants et al 31 Mar 2020 UK	27 studies describing 31 prediction models One study of patients in Italy, the remainder in China	Rapid systematic review and critical appraisal	10 prognostic models reviewed	All available prognostic models based on inpatient data. “because all models were at high risk of bias, we do not recommend their routine use before they are properly externally validated.”	Majority of studies included have not yet been published. Other risk calculators in clinical use not reviewed as manuscript not available.

Comment(s)

Given the possibility of health systems becoming overwhelmed during the COVID-19 pandemic, a risk-stratification tool is badly needed to differentiate between patients who are safe to go home and those who may deteriorate and require oxygen or other treatment in hospital. This urgency may account for the fact that some models are being used clinically without first having been robustly validated in the relevant population. The literature on COVID-19 is being rapidly updated as understanding of the condition and its management improves. It is likely that more robust risk stratification tools will become available given their utility in the present pandemic.

Clinical Bottom Line

There is no validated risk stratification tool that can currently be recommended for patients with suspected or confirmed COVID-19 attending the Emergency Department.

References

1. Wynants L, Van Calster B, Bonten M et al. Prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal BMJ BMJ2020;369:m1328