RT Journal Article
SR Electronic
T1 External validation of triage tools for adults with suspected COVID-19 in a middle-income setting: an observational cohort study
JF Emergency Medicine Journal
JO Emerg Med J
FD BMJ Publishing Group Ltd and the British Association for Accident & Emergency Medicine
SP emermed-2022-212827
DO 10.1136/emermed-2022-212827
A1 Carl Marincowitz
A1 Laura Sbaffi
A1 Madina Hasan
A1 Peter Hodkinson
A1 David McAlpine
A1 Gordon Fuller
A1 Steve Goodacre
A1 Peter A Bath
A1 Yasein Omer
A1 Lee A Wallis
YR 2023
UL http://emj.bmj.com/content/early/2023/05/22/emermed-2022-212827.abstract
AB Background Tools proposed to triage ED acuity in suspected COVID-19 were derived and validated in higher income settings during early waves of the pandemic. We estimated the accuracy of seven risk-stratification tools recommended to predict severe illness in the Western Cape, South Africa.Methods An observational cohort study using routinely collected data from EDs across the Western Cape, from 27 August 2020 to 11 March 2022, was conducted to assess the performance of the PRIEST (Pandemic Respiratory Infection Emergency System Triage) tool, NEWS2 (National Early Warning Score, version 2), TEWS (Triage Early Warning Score), the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS (Pandemic Medical Early Warning Score) in suspected COVID-19. The primary outcome was intubation or non-invasive ventilation, death or intensive care unit admission at 30 days.Results Of the 446 084 patients, 15 397 (3.45%, 95% CI 34% to 35.1%) experienced the primary outcome. Clinical decision-making for inpatient admission achieved a sensitivity of 0.77 (95% CI 0.76 to 0.78), specificity of 0.88 (95% CI 0.87 to 0.88) and the negative predictive value (NPV) of 0.99 (95% CI 0.99 to 0.99). NEWS2, PMEWS and PRIEST scores achieved good estimated discrimination (C-statistic 0.79 to 0.82) and identified patients at risk of adverse outcomes at recommended cut-offs with moderate sensitivity (>0.8) and specificity ranging from 0.41 to 0.64. Use of the tools at recommended thresholds would have more than doubled admissions, with only a 0.01% reduction in false negative triage.Conclusion No risk score outperformed existing clinical decision-making in determining the need for inpatient admission based on prediction of the primary outcome in this setting. Use of the PRIEST score at a threshold of one point higher than the previously recommended best approximated existing clinical accuracy.Data may be obtained from a third party and are not publicly available. The data used for this study are subject to a data sharing agreement with the Western Cape Government Department of Health and Wellness, which prohibits further sharing of patient-level data. Access to these and related data should be requested directly from this organisation and is subject to the necessary ethical and organisational approval processes.