Development and validation of an early warning score (EWAS) for predicting clinical deterioration in patients with coronavirus disease 2019

Guo, Yabing; Liu, Yingxia; Lu, Jiatao; Fan, Rong; Zhang, Fuchun; Yin, Xueru; Liu, Zhihong; Zeng, Qinglang; Yuan, Jing; Hu, Shufang; Wang, Qiongya; Liao, Baolin; Huang, Mingxing; Yin, Sichun; Zhang, Xilin; Xin, Rui; Lin, Zhanzhou; Hu, Changzheng; Zhao, Boliang; He, Ridong; Liang, Minfeng; Zhang, Zheng; Liu, Li; Sun, Jian; Tang, Lu; Deng, Lisi; Xia, Jinyu; Tang, Xiaoping; Liu, Lei; Hou, Jinlin

Background: Since the pandemic outbreak of coronavirus disease 2019 (COVID-19), the health system capacity in highly endemic areas has been overwhelmed. Approaches to efficient management are urgently needed. We aimed to develop and validate a score for early prediction of clinical deterioration of COVID-19 patients. Methods: In this retrospective multicenter cohort study, we included 1138 mild to moderate COVID-19 patients admitted to 33 hospitals in Guangdong Province from December 27, 2019 to March 4, 2020 (N =818; training cohort), as well as two hospitals in Hubei Province from January 21 to February 22, 2020 (N =320; validation cohort) in the analysis. Results: The 14-day cumulative incidences of clinical deterioration were 7.9% and 12.1% in the training and validation cohorts, respectively. An Early WArning Score (EWAS) (ranging from 0 to 4.5), comprising of age, underlying chronic disease, neutrophil to lymphocyte ratio, C-reactive protein, and D-dimer levels, was developed (AUROC: 0.857). By applying the EWAS, patients were categorized into low-, medium-, and high risk groups (cut-off values: two and three). The 14-day cumulative incidence of clinical deterioration in the low-risk group was 1.8%, which was significantly lower than the incidence rates in the medium- (14.4%) and high-risk (40.9%) groups (P <.001). The predictability of EWAS was similar in the validation cohort (AUROC =0.781), patients in the low-, medium-, and high-risk groups had 14-day cumulative incidences of 2.6%, 10.0%, and 25.7%, respectively (P <.001). Conclusion: The EWAS, which is based on five common parameters, can predict COVID-19-related clinical deterioration and may be a useful tool for a rapid triage and establishing a COVID-19 hierarchical management system that will greatly focus clinical management and medical resources to reduce mortality in highly endemic areas.