Increase in COVID-19 inpatient survival following detection of Thromboembolic and Cytokine storm risk from the point of admission to hospital by a near real time Traffic-light System (TraCe-Tic)

Vizcaychipi, Marcela P.; Shovlin, Claire L.; McCarthy, Alex; Godfrey, Andrew; Patel, Sheena; Shah, Pallav L.; Hayes, Michelle; Keays, Richard T.; Beveridge, Iain

INTRODUCTION: Our goal was to evaluate if traffic-light driven personalized care for COVID-19 was associated with improved survival in acute hospital settings. METHODS: Discharge outcomes were evaluated before and after prospective implementation of a real-time dashboard with feedback to ward-based clinicians. Thromboembolic categories were “medium-risk” (D-dimer >1,000 ng/mL or CRP >200 mg/L); “high-risk” (D-dimer >3,000 ng/mL or CRP > 250 mg/L) or “suspected” (D-dimer >5,000 ng/mL). Cytokine storm risk was categorized by ferritin. RESULTS: 939/1039 COVID-19 positive patients (median age 69ys, 563/939 (60%) male) completed hospital encounters to death or discharge by 21(st) May 2020. Thromboembolic flag criteria were reached by 568/939 (60.4%), including 238/275 (86.6%) of the patients who died, and 330/664 (49.7%) of the patients who survived to discharge, p < 0.0001. Cytokine storm flag criteria were reached by 212 (22.5%) of admissions, including 80/275 (29.0%) of the patients who died, and 132/664 (19.9%) of the patients who survived, p < 0.0001. The maximum thromboembolic flag discriminated completed encounter mortality (no flag: 37/371 [9.97%] died; medium-risk: 68/239 [28.5%]; high-risk: 105/205 [51.2%]; and suspected thromboembolism: 65/124 [52.4%], p < 0.0001). Flag criteria were reached by 535 consecutive COVID-19 positive patients whose hospital encounter completed before traffic-light introduction: 173/535 (32.3% [95% confidence intervals 28.0, 36.0]) died. For the 200 consecutive admissions after implementation of real-time traffic light flags, 46/200 (23.0% [95% confidence intervals 17.1 - 28.9]) died, p = 0.013. Adjusted for age and sex, the probability of death was 0.33 (95% confidence intervals 0.30 - 0.37) before traffic light implementation, 0.22 (0.17 - 0.27) after implementation, p < 0.001. In subgroup analyses, older patients, males, and patients with hypertension (p ≤0.01), and/or diabetes (p = 0.05) derived the greatest benefit from admission under the traffic light system. CONCLUSION: Personalized early interventions were associated with a 33% reduction in early mortality. We suggest benefit predominantly resulted from early triggers to review/enhance anticoagulation management, without exposing lower-risk patients to potential risks of full anticoagulation therapy.