Stratifying Deterioration Risk by Acuity at Admission Offers Triage Insights for Coronavirus Disease 2019 Patients.
Objectives
Triaging patients at admission to determine subsequent deterioration risk can be difficult. This is especially true of coronavirus disease 2019 patients, some of whom experience significant physiologic deterioration due to dysregulated immune response following admission. A well-established acuity measure, the Rothman Index, is evaluated for stratification of patients at admission into high or low risk of subsequent deterioration.


Design
Multicenter retrospective study.


Setting
One academic medical center in Connecticut, and three community hospitals in Connecticut and Maryland.


Patients
Three thousand four hundred ninety-nine coronavirus disease 2019 and 14,658 noncoronavirus disease 2019 adult patients admitted to a medical service between January 1, 2020, and September 15, 2020.


Interventions
None.


Measurements and Main Results
Performance of the Rothman Index at admission to predict in-hospital mortality or ICU utilization for both general medical and coronavirus disease 2019 populations was evaluated using the area under the curve. Precision and recall for mortality prediction were calculated, high- and low-risk thresholds were determined, and patients meeting threshold criteria were characterized. The Rothman Index at admission has good to excellent discriminatory performance for in-hospital mortality in the coronavirus disease 2019 (area under the curve, 0.81-0.84) and noncoronavirus disease 2019 (area under the curve, 0.90-0.92) populations. We show that for a given admission acuity, the risk of deterioration for coronavirus disease 2019 patients is significantly higher than for noncoronavirus disease 2019 patients. At admission, Rothman Index-based thresholds segregate the majority of patients into either high- or low-risk groups; high-risk groups have mortality rates of 34-45% (coronavirus disease 2019) and 17-25% (noncoronavirus disease 2019), whereas low-risk groups have mortality rates of 2-5% (coronavirus disease 2019) and 0.2-0.4% (noncoronavirus disease 2019). Similarly large differences in ICU utilization are also found.


Conclusions
Acuity level at admission may support rapid and effective risk triage. Notably, in-hospital mortality risk associated with a given acuity at admission is significantly higher for coronavirus disease 2019 patients than for noncoronavirus disease 2019 patients. This insight may help physicians more effectively triage coronavirus disease 2019 patients, guiding level of care decisions and resource allocation.
['Beals|Joseph|J|', 'Barnes|Jaime J|JJ|', 'Durand|Daniel J|DJ|', 'Rimar|Joan M|JM|', 'Donohue|Thomas J|TJ|', 'Hoq|S Mahfuz|SM|', 'Belk|Kathy W|KW|', 'Amin|Alpesh N|AN|', 'Rothman|Michael J|MJ|']
coronavirus disease 2019 clinical decision rules decision support systems hospital mortality patient acuity risk assessment