Predicting poor outcome in patients with suspected COVID-19 presenting to the Emergency Department (COVERED) – Development, internal and external validation of a prediction model
Authors:   Emergency Department, Amsterdam Public Health Research Institute, Azijli K. , Lieveld A.W.E. ,   Department of Internal Medicine, Amsterdam Public Health Research Institute, van der Horst S.F.B. ,   Department of Internal Medicine, Amsterdam Public Health Research Institute, de Graaf N. ,   Fondazione Poliambulanza, Brescia, Italy, Kootte R.S. ,   Department of Internal Medicine, Amsterdam UMC, Heijmans M.W. ,   Department of Epidemiology & Data Science, van de Ven P.M. ,   Department of Epidemiology & Data Science, Peters E.J.G. ,   Department of Internal Medicine, Amsterdam Public Health Research Institute, Heijmans J. ,   Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Terragnoli P. ,   Fondazione Poliambulanza, Instituto Ospedaliero, Brescia, Italy, Natalini G. ,   Fondazione Poliambulanza Instituto Ospedaliero, Brescia, Italy, Abu Hilal M. ,   Fondazione Poliambulanza, Brescia, Italy, de Rooij T. ,   Emergency Department, Amsterdam Public Health Research Institute, Nanayakkara P.W.B. ,   Department of Internal Medicine, Amsterdam Public Health Research Institute
Published: June 2021

Background: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed. Objective: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome. Methods: In this prospective, multi-centre study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort. Results: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75). Conclusion: The COVERED risk score showed excellent discriminatory ability, also in external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.