Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study

Demir, Mehmet Cihat; Ilhan, Buğra

doi:10.1590/1516-3180.2020.0649.R1.10122020

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Sao Paulo Medical Journal

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Original Article • Sao Paulo Med. J. 139 (2) • Mar-Apr 2021 • https://doi.org/10.1590/1516-3180.2020.0649.R1.10122020 copy

Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use.

OBJECTIVES:

To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting.

DESIGN AND SETTING:

Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey.

METHODS:

PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis.

RESULTS:

One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO₂) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05).

CONCLUSIONS:

CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO₂ and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.

KEY WORDS (MeSH terms):
COVID-19 [supplementary concept]; Emergency service, hospital; Pandemics; Pneumonia; Triage

AUTHORS’ KEY WORDS:
CURB-65; PMEWS; STSS; Triage scores.

	n = 100	30-day mortality		P
	n = 100	Yes	No	P
Female	54	4	50	0.684
Comorbid disease	43	6	37	0.005
Smoking habit	19	1	18	1.0
Symptoms
Fever	29	4	25	0.057
Cough	52	4	48	0.679
Dyspnea	15	2	13	0.220
Myalgia	15	1	14	1.0
Sore throat	7	0	7	1.0
Diarrhea	2	1	1	0.117
Loss of taste	3	0	3	1.0
Loss of smell	1	0	1	1.0
Headache	2	0	2	1.0
Asymptomatic	24	0	24	0.331
Pathological CT findings	77	6	71	0.385
Need for MV	15	6	9	< 0.001
Hospitalization/discharge outcomes
Discharge	40	0	40	< 0.001
Ward admission	50	0	50
ICU admission	10	6	4

	30-day mortality		P	All patients
	Yes	No	P	All patients
Age^a (year)	72.67 ± 15.73	49.38 ± 15.89	0.001^*	50.78 ± 16.75
SBP^b (mmHg)	114.5 (89.5-141.5)	125 (117.75-140)	0.225^**	125 (116.25-139.75)
DBP^a (mmHg)	66.5 ± 13.47	75.83 ± 13.56	0.105^*	75.27 ± 13.67
Heart rate^b (beats/min)	90 (78.25-112.5)	88 (78.75-99.5)	0.566^**	88 (79.0-100.5)
Respiratory rate^b (breaths/min)	20 (14-27)	14 (14-16)	0.028 ^**	14 (14-16)
SpO₂ ^b (%)	86.5 (57.5-93.25)	96 (94-98)	0.002 ^**	96 (94-98)
Fever^b (°C)	36.15 (36.07-38.72)	36.8 (36.27-37.4)	0.541^**	36.8 (36.2-37.4)
Shock index^b	0.74 (0.65-1.1)	0.67 (0.59-0.77)	0.117^**	0.67 (0.60-0.77)
LOS in ED^b (hour)	5.5 (2.75-6.25)	3 (2-4)	0.039 ^**	3.0 (2-4)
LOS in hospital^b (day)	6 (2.75-11)	4.5 (0-8)	0.186^**	4.5 (0-8)

	30-day mortality		P	ICU admission		P	Need for MV		P
	Yes	No	P	Yes	No	P	Yes	No	P
PMEWS
0-3	0	77	< 0.001 ^*	1	76	< 0.001 ^*	5	72	< 0.001 ^*
4	1	6		1	6		1	6
5	0	4		0	4		0	4
6	0	3		1	2		1	2
7	1	2		2	1		3	0
8	1	2		2	1		2	1
12	1	0		1	0		1	0
13	1	0		1	0		1	0
14	1	0		1	0		1	0
CURB-65
0	0	62	< 0.001 ^*	1	61	< 0.001 ^*	2	60	< 0.001 ^*
1	1	23		1	23		3	21
2	2	7		4	5		6	3
3	1	2		2	1		2	1
4	2	0		2	0		2	0
STSS
0	0	66	< 0.001 ^*	1	65	< 0.001 ^*	3	63	< 0.001 ^*
1	1	22		3	20		5	18
2	1	5		2	4		2	4
3	2	1		2	1		3	0
4	2	0		2	0		2	0

	AUC	95% CI	Sensitivity (%)	Specificity (%)	+LR	−LR	PPV	NPV	P
Mortality
PMEWS ≥ 3	0.968	0.912-0.993	100	81.91	5.53	0.0	26.08	100.0	< 0.001 ^*
CURB-65 ≥ 1	0.942	0.877-0.979	83.33	90.43	8.70	0.18	35.72	98.83	< 0.001 ^*
STSS ≥ 1	0.962	0.903-0.990	83.33	93.62	13.06	0.18	45.46	98.87	< 0.001 ^*
ICU admission
PMEWS ≥ 5	0.941	0.875-0.978	80	95.56	18	0.21	66.68	97.72	< 0.001 ^*
CURB-65 ≥ 1	0.898	0.821-0.949	80	93.33	12	0.21	57.13	97.67	< 0.001 ^*
STSS ≥ 1	0.878	0.798-0.935	90	72.22	3.24	0.14	26.46	98.48	< 0.001 ^*
Need for MV
PMEWS ≥ 5	0.854	0.769-0.917	60	96.47	17	0.41	74.99	93.18	< 0.001 ^*
CURB-65 ≥ 1	0.867	0.785-0.927	66.67	95.29	14.17	0.35	71.4	94.18	< 0.001 ^*
STSS ≥ 1	0.820	0.731-0.890	80	74.12	3.09	0.27	35.29	95.45	< 0.001 ^*

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[1] Address for correspondence: Mehmet Cihat Demir. Department of Emergency Medicine, School of Medicine, Düzce University, 81620, Düzce, Turkey. Tel. (+90) 380 542 14 16, extension 6559. E-mail: mdcihat@gmail.com