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Development and validation of an early warning score (EWAS) for predicting clinical deterioration in patients with coronavirus disease 2019

By Yabing Guo, Yingxia Liu, Jiatao Lu, Rong Fan, Fuchun Zhang, Xueru Yin, Zhihong Liu, Qinglang Zeng, Jing Yuan, Shufang Hu, Qiongya Wang, Baolin Liao, Mingxing Huang, Sichun Yin, Xilin Zhang, Rui Xin, Zhanzhou Lin, Changzheng Hu, Boliang Zhao, Ridong He, Minfeng Liang, Zheng Zhang, Li Liu, Jian Sun, Lu Tang, Lisi Deng, Jinyu Xia, Xiaoping Tang, Lei Liu, Jinlin Hou

Posted 21 Apr 2020
medRxiv DOI: 10.1101/2020.04.17.20064691

Background: Since the pandemic outbreak of coronavirus disease 2019 (COVID-19), the health system capacity in highly endemic areas has been overwhelmed. Approaches to efficient management are urgently needed. We aimed to develop and validate a score for early prediction of clinical deterioration of COVID-19 patients. Methods: In this retrospective multicenter cohort study, we included 1138 mild to moderate COVID-19 patients admitted to 33 hospitals in Guangdong Province from December 27, 2019 to March 4, 2020 (N =818; training cohort), as well as two hospitals in Hubei Province from January 21 to February 22, 2020 (N =320; validation cohort) in the analysis. Results: The 14-day cumulative incidences of clinical deterioration were 7.9% and 12.1% in the training and validation cohorts, respectively. An Early WArning Score (EWAS) (ranging from 0 to 4.5), comprising of age, underlying chronic disease, neutrophil to lymphocyte ratio, C-reactive protein, and D-dimer levels, was developed (AUROC: 0.857). By applying the EWAS, patients were categorized into low-, medium-, and high risk groups (cut-off values: two and three). The 14-day cumulative incidence of clinical deterioration in the low-risk group was 1.8%, which was significantly lower than the incidence rates in the medium- (14.4%) and high-risk (40.9%) groups (P <.001). The predictability of EWAS was similar in the validation cohort (AUROC =0.781), patients in the low-, medium-, and high-risk groups had 14-day cumulative incidences of 2.6%, 10.0%, and 25.7%, respectively (P <.001). Conclusion: The EWAS, which is based on five common parameters, can predict COVID-19-related clinical deterioration and may be a useful tool for a rapid triage and establishing a COVID-19 hierarchical management system that will greatly focus clinical management and medical resources to reduce mortality in highly endemic areas.

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