Identification on Admission of COVID 19 Patients at Risk of Subsequent Rapid Clinical Deterioration

Introduction Recent localized surges in COVID-19 cases have resulted in the hospitals serving those areas being overwhelmed. In such cases, the ability to rapidly and objectively determine a patient’s acuity and predict near-term care needs is a major challenge. At issue is the clinician’s ability to correctly identify patients at risk for subsequent rapid clinical deterioration. Data-driven tools that can support such determinations in real-time may be a valuable adjunct to clinician judgement during COVID-19 surges. Objective To assess the effectiveness of the Rothman Index (RI) predictive model in distinguishing the risk of subsequent deterioration or elevated care needs among hospitalized COVID-19 patients at the time of hospital admission. Methods We evaluated the initial RI score on admission to predict COVID-19 patient risk for 216 COVID-19 patients discharged from March 21st to June 7th, 2020 at Sinai LifeBridge Hospital and 1,453 COVID-19 patients discharged from any of Yale New Haven Health System’s Yale New Haven, Bridgeport, and Greenwich hospitals from April 1st to April 28th, 2020. In-hospital mortality as a function of age and RI on admission for COVID-19 and non-COVID-19 patients were compared. AUC values using each COVID-19 patient’s initial RI on admission to predict in-hospital mortality, mechanical ventilation, and ICU utilization were computed, as were precision and recall for mortality prediction at specific RI thresholds. Results The RI computed at the time of admission provides a high degree of objective discrimination to differentiate the COVID-19 population into high and low risk populations at the outset of hospitalization. The high risk segment based on initial RI constitutes 20-30% of the COVID-19 positive population with mortality rates from 40-50%. The low risk segment based on initial RI constitutes 40%-55% of the population with mortality rates ranging from 1%-8%. Of note is that COVID-19 patients who present with heightened but generally unremarkable acuity can be identified early as having considerably elevated risk for subsequent physiological deterioration. Conclusion COVID-19 patients exhibit elevated mortality rates compared to non-COVID-19 medical service patients and may be subject to rapid deterioration following hospital admission. A lack of predictive indicators for identifying patients at high risk of subsequent deterioration or death can pose a challenge to clinicians. The RI has excellent performance characteristics when stratifying risk among COVID-19 patients at the time of admission. The RI can assist clinicians in real-time with a high degree of objective discrimination by segmenting the COVID-19 population into high and low risk populations. This supports rapid and optimal patient bed assignment and resource allocation. ### Competing Interest Statement J. Beals, K. Belk, and M. Rothman are employees of PeraHealth, Inc. and J. Beals and M. Rothman are equity owners of PeraHealth, Inc. ### Funding Statement No third party funding was received. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This research was approved by both the Sinai LifeBridge Hospital and Yale New Haven Health Bridgeport Hospital Institutional Review Boards. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes This work entailed an IRB approved study of retrospective data.