Predictive Value of an Age-Based Modification of the National Early Warning System in Hospitalized Patients With COVID-19

Ryan C Maves; Stephanie A Richard; David A Lindholm; Nusrat Epsi; Derek T Larson; Christian Conlon; Kyle Everson; Steffen Lis; Paul W Blair; Sharon Chi; Anuradha Ganesan; Simon Pollett; Timothy H Burgess; Brian K Agan; Rhonda E Colombo; Christopher J Colombo; EPICC COVID-19 Cohort Study Group

doi:10.1093/ofid/ofab421

Predictive Value of an Age-Based Modification of the National Early Warning System in Hospitalized Patients With COVID-19

Open Forum Infect Dis. 2021 Aug 10;8(12):ofab421. doi: 10.1093/ofid/ofab421. eCollection 2021 Dec.

Authors

Ryan C Maves^{1

2

3}, Stephanie A Richard^{1

4}, David A Lindholm^{5

6}, Nusrat Epsi^{1

4}, Derek T Larson⁷, Christian Conlon⁸, Kyle Everson⁸, Steffen Lis⁸, Paul W Blair^{9

10}, Sharon Chi^{1

4

11}, Anuradha Ganesan^{1

4

12}, Simon Pollett^{1

4}, Timothy H Burgess¹, Brian K Agan^{1

4}, Rhonda E Colombo^{1

4

8}, Christopher J Colombo^{6

8}; EPICC COVID-19 Cohort Study Group

Collaborators

EPICC COVID-19 Cohort Study Group:
J Cowden, D Lindholm, A Markelz, K Mende, S Merritt, T Merritt, R Walter, T Wellington, S Bazan, S Michel, L Brandon, E Ewers, K Gallagher, D Larson, M Odom, C Colombo, R Colombo, C Conlon, K Everson, P Faestel, T Ferguson, L Gordon, S Grogan, S Lis, M Martin, C Mount, D Musfeldt, D Odineal, W Robb-McGrath, R Sainato, C Schofield, C Skinner, M Stein, M Switzer, M Timlin, S Wood, G Atwood, R Carpenter, C Eickhoff, K Kronmann, T Lalani, T Lee, T Warkentien, J Arnold, C Berjohn, S Husain, N Kirkland, A Lane, R Maves, J Parrish, G Utz, S Chi, E Filan, K Fong, S Hopkinson, T Horseman, M Jones, A Kanis, A Kayatani, W Londeree, C Madar, J Masel, M McMahon, K Miyasato, G Murphy, V Nguay, K O'Connor, P Schmidt, E Schoenman, S Scrivner, C Uyehara, R Villacortalyew, B Agan, C Broder, D Brody, T Burgess, C Byrne, K Chung, C Coles, C Dalgard, J S Dumler, C English, M Haigney, P Hickey, E Laing, J Livezey, A Malloy, R McLeroy, E Millar, T Oliver, S Pollett, M Rajnik, S Richard, J Rozman, J Rusiecki, M Sanchez, A Scher, M Simons, A Snow, D Tribble, I Berry, J Currier, J Darden, H Friberg, C Lanteri, S Peel, P Bhatia, A Ganesan, N Huprikar, M Oyeneyin, M Banda, B Davis, T Hunter, O Ikpekpe-Magege, S Kemp, R Mody, R Resendez, A Farmer, D Hostler, C Maldonado, J Mehrer, R Radcliffe, D Shaha, M Swain, J Weiss

Affiliations

¹ Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
² Naval Medical Center San Diego, San Diego, California, USA.
³ Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
⁴ Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland, USA.
⁵ Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas, USA.
⁶ Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
⁷ Fort Belvoir Community Hospital, Fort Belvoir, Virginia, USA.
⁸ Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA.
⁹ Austere Environments Consortium for Enhanced Sepsis Outcomes, Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA.
¹⁰ Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
¹¹ Tripler Army Medical Center, Honolulu, Hawaii, USA.
¹² Walter Reed National Military Medical Center, Bethesda, Maryland, USA.

Abstract

Background: Early recognition of high-risk patients with coronavirus disease 2019 (COVID-19) may improve outcomes. Although many predictive scoring systems exist, their complexity may limit utility in COVID-19. We assessed the prognostic performance of the National Early Warning Score (NEWS) and an age-based modification (NEWS+age) among hospitalized COVID-19 patients enrolled in a prospective, multicenter US Military Health System (MHS) observational cohort study.

Methods: Hospitalized adults with confirmed COVID-19 not requiring invasive mechanical ventilation at admission and with a baseline NEWS were included. We analyzed each scoring system's ability to predict key clinical outcomes, including progression to invasive ventilation or death, stratified by baseline severity (low [0-3], medium [4-6], and high [≥7]).

Results: Among 184 included participants, those with low baseline NEWS had significantly shorter hospitalizations (P < .01) and lower maximum illness severity (P < .001). Most (80.2%) of low NEWS vs 15.8% of high NEWS participants required no or at most low-flow oxygen supplementation. Low NEWS (≤3) had a negative predictive value of 97.2% for progression to invasive ventilation or death; a high NEWS (≥7) had high specificity (93.1%) but low positive predictive value (42.1%) for such progression. NEWS+age performed similarly to NEWS at predicting invasive ventilation or death (NEWS+age: area under the receiver operating characteristics curve [AUROC], 0.69; 95% CI, 0.65-0.73; NEWS: AUROC, 0.70; 95% CI, 0.66-0.75).

Conclusions: NEWS and NEWS+age showed similar test characteristics in an MHS COVID-19 cohort. Notably, low baseline scores had an excellent negative predictive value. Given their easy applicability, these scoring systems may be useful in resource-limited settings to identify COVID-19 patients who are unlikely to progress to critical illness.

Keywords: COVID-19; early warning score; prognosis.

Published by Oxford University Press on behalf of Infectious Diseases Society of America 2021.