New calculators could allow clinicians to better stratify risk in patients infected with COVID
Two new calculators to predict which patients admitted to hospital with COVID-19 are most at risk of requiring mechanical ventilation or of hospital death have been developed and validated by the Massachusetts General Hospital (MGH).
In a study published in The Lancet’s EClinicalMedicine, the researchers describe how these models could allow clinicians to better stratify risk in patients infected with COVID to optimize care and resource use in hospitals facing critical care capacity constraints.
There is limited information to accurately predict the severity of the clinical course at the time of admission to hospital. Using a combination of medical history, vital signs and laboratory results at the time of patient admission, we have developed models that can differentiate the risk of mechanical ventilation and the risk of in-hospital mortality. While other studies have focused on 30-day hospital outcomes, we have followed all COVID-19 patients through to the end of their hospital journey, as a significant number are hospitalized well beyond 30 days. “
Rajeev Malhotra, MD, senior study author and cardiologist, Massachusetts General Hospital
The research team compiled this clinical information from 1,042 confirmed patients with COVID-19 who were admitted to five hospitals in the Mass General Brigham health system during the first three months of the pandemic.
Significant associations between clinical, hemodynamic and laboratory data and parameters of in-hospital mortality and mechanical ventilation provided the building blocks for two distinct models of risk stratification known as VICE scores (Ventilation in COVID Estimate. ) and DICE (Death in COVID Estimate).
The VICE predictors discovered by the researchers were diabetes mellitus, blood oxygen saturation, and two inflammatory markers: C-reactive protein and lactate dehydrogenase. DICE predictors of mortality were age, male gender, coronary artery disease, diabetes mellitus, body mass index, platelet count, and various inflammatory and infectious markers.
“By entering clinical values into these online calculators, physicians can stratify patients with COVID-19 upon admission and determine those who may require the most intensive care and management,” says lead author Christopher Nicholson , PhD, Principal Investigator at MGH Cardiovascular Research Center.
“These risk scores allow them to predict with greater than 80% accuracy – higher than established models – patient outcomes, as well as the demand for mechanical ventilators and intensive care beds, which could impact end-of-life decisions involving COVID-19 patients. “
The researchers were surprised to learn that age was not a significant predictor of a patient’s need for mechanical ventilation. Indeed, apart from the youngest patients, the percentage of hospitalized COVID-19 patients requiring mechanical ventilation was similar over each decade of life, although there was a clear correlation between age and condition. risk of death in hospital, with only 15% survival in patients over 84 years requiring mechanical ventilation.
Age was also not a predictor of how long a patient would need ventilation. The study found that 59% of patients in the 25-34 age group needed more than 14 days of ventilation, as in the older groups.
“We were amazed to see the impact of this disease on young people admitted to hospital,” says Nicholson. “Our data has shown that they are just as likely to be put on a mechanical ventilator as the elderly and to need a long duration of ventilation.”
Another important finding from the study was that regular statin use was associated with reduced hospital mortality, underscoring the strong links between COVID-19, cardiovascular disease, and inflammation. In another encouraging finding, researchers observed no relationship between the minority ethnicity of COVID-19 patients and worse clinical outcomes after adjusting for clinical risk.
“What we’ve generally learned from this disease is how different it is from any others we’ve seen in intensive care,” says Malhotra, who has managed COVID patients in the intensive care unit. heart attacks in the past year. “For this reason, we have focused on developing a new approach to assess and predict outcomes with our risk stratification calculator.”
Massachusetts General Hospital
Nicholson, Chief Justice, et al. (2021) Estimating the risk of mechanical ventilation and in-hospital mortality in adult patients with COVID-19 admitted to Mass General Brigham: VICE and DICE scores. EClinicalMedicine. doi.org/10.1016/j.eclinm.2021.100765.