Critical Care Explorations (Jul 2021)

Performance Analysis of the National Early Warning Score and Modified Early Warning Score in the Adaptive COVID-19 Treatment Trial Cohort

  • Christopher J. Colombo, MD, MA, FACP, FCCM,
  • Rhonda E. Colombo, MD, MHS, FACP, FIDSA,
  • Ryan C. Maves, MD, FCCM, FCCP, FIDSA,
  • Angela R. Branche, MD,
  • Stuart H. Cohen, MD,
  • Marie-Carmelle Elie, MD,
  • Sarah L. George, MD,
  • Hannah J. Jang, PhD, RN, CNL, PHN,
  • Andre C. Kalil, MD, MPH,
  • David A. Lindholm, MD, FACP,
  • Richard A. Mularski, MD, MSHS, MCR, ATSF, FCCP, FACP,
  • Justin R. Ortiz, MD, MS, FACP, FCCP,
  • Victor Tapson, MD,
  • C. Jason Liang, PhD,
  • On behalf of the ACTT-1 Study Group,
  • Aneesh K. Mehta,
  • Nadine G. Rouphael,
  • Jessica J. Traenkner,
  • Valeria D Cantos,
  • Ghina Alaaeddine,
  • Barry S. Zingman,
  • Robert Grossberg,
  • Paul F. Riska,
  • Elizabeth Hohmann,
  • Mariam Torres-Soto,
  • Nikolaus Jilg,
  • Helen Y. Chu,
  • Anna Wald,
  • Margaret Green,
  • Annie Luetkemeyer,
  • Pierre-Cedric B. Crouch,
  • Hannah Jang,
  • Susan Kline,
  • Joanne Billings,
  • Brooke Noren,
  • Diego Lopez de Castilla,
  • Jason W. Van Winkle,
  • Francis X. Riedo,
  • Robert W. Finberg,
  • Jennifer P. Wang,
  • Mireya Wessolossky,
  • Kerry Dierberg,
  • Benjamin Eckhardt,
  • Henry J Neumann,
  • Victor Tapson,
  • Jonathan Grein,
  • Fayyaz Sutterwala,
  • Lanny Hsieh,
  • Alpesh N. Amin,
  • Thomas F. Patterson,
  • Heta Javeri,
  • Trung Vu,
  • Roger Paredes,
  • Lourdes Mateu,
  • Daniel A. Sweeney,
  • Constance A. Benson,
  • Farhana Ali,
  • William R. Short,
  • Pablo Tebas,
  • Jessie Torgersen,
  • Giota Touloumi,
  • Vicky Gioukari,
  • David Chien Lye,
  • Sean WX Ong,
  • Norio Ohmagari,
  • Ayako Mikami,
  • Gerd Fätkenheuer,
  • Jakob J. Malin,
  • Philipp Koehler,
  • Andre C. Kalil,
  • LuAnn Larson,
  • Angela Hewlett,
  • Mark G. Kortepeter,
  • C. Buddy Creech,
  • Isaac Thomsen,
  • Todd W. Rice,
  • Babafemi Taiwo,
  • Karen Krueger,
  • Stuart H. Cohen,
  • George R. Thompson, 3rd,
  • Cameron Wolfe,
  • Emmanuel B. Walter,
  • Maria Frank,
  • Heather Young,
  • Ann R. Falsey,
  • Angela R. Branche,
  • Paul Goepfert,
  • Nathaniel Erdmann,
  • Otto O. Yang,
  • Jenny Ahn,
  • Anna Goodman,
  • Blair Merrick,
  • Richard M. Novak,
  • Andrea Wendrow,
  • Henry Arguinchona,
  • Christa Arguinchona,
  • Sarah L. George,
  • Janice Tennant,
  • Robert L. Atmar,
  • Hana M. El Sahly,
  • Jennifer Whitaker,
  • D. Ashley Price,
  • Christopher J. A. Duncan,
  • Simeon Metallidis,
  • Theofilos Chrysanthidis,
  • F. McLellan,
  • Myoung-don Oh,
  • Wan Beom Park,
  • Eu Suk Kim,
  • Jongtak Jung,
  • Justin R. Ortiz,
  • Karen L. Kotloff,
  • Brian Angus,
  • Jack David Germain Seymour,
  • Noreen A. Hynes,
  • Lauren M. Sauer,
  • Neera Ahuja,
  • Kari Nadeau,
  • Patrick E. H. Jackson,
  • Taison D. Bell,
  • Anastasia Antoniadou,
  • Konstantinos Protopapas,
  • Richard T Davey,
  • Jocelyn D. Voell,
  • Jose Muñoz,
  • Montserrat Roldan,
  • Ioannis Kalomenidis,
  • Spyros G. Zakynthinos,
  • Catharine I. Paules,
  • Fiona McGill,
  • Jane Minton,
  • Nikolaos Koulouris,
  • Zafeiria Barmparessou,
  • Edwin Swiatlo,
  • Kyle Widmer,
  • Nikhil Huprikar,
  • Anuradha Ganesan,
  • Guillermo M. Ruiz-Palacios,
  • Alfredo Ponce de León,
  • Sandra Rajme,
  • Justino Regalado Pineda,
  • José Arturo Martinez-Orozco,
  • Mark Holodniy,
  • Aarthi Chary,
  • Timo Wolf,
  • Christoph Stephan,
  • Jan-Christian Wasmuth,
  • Christoph Boesecke,
  • Martin Llewelyn,
  • Barbara Philips,
  • Christopher J. Colombo,
  • Rhonda E. Colombo,
  • David A. Lindholm,
  • Katrin Mende,
  • Tida Lee,
  • Tahaniyat Lalani,
  • Ryan C. Maves,
  • Gregory C. Utz,
  • Jens Lundgren,
  • Marie Helleberg,
  • Jan Gerstoft,
  • Thomas Benfield,
  • Tomas Jensen,
  • Birgitte Lindegaard,
  • Lothar Weise,
  • Lene Knudsen,
  • Isik Johansen,
  • Lone W Madsen,
  • Lars Østergaard,
  • Nina Stærke,
  • Henrik Nielsen,
  • Timothy H. Burgess,
  • Michelle Green,
  • Mat Makowski,
  • Jennifer L. Ferreira,
  • Michael R. Wierzbicki,
  • Tyler Bonnett,
  • Nikki Gettinger,
  • Theresa Engel,
  • Jing Wang,
  • John H. Beigel,
  • Kay M. Tomashek,
  • Seema Nayak,
  • Lori E. Dodd,
  • Walla Dempsey,
  • Effie Nomicos,
  • Marina Lee,
  • Peter Wolff,
  • Rhonda PikaartTautges,
  • Mohamed Elsafy,
  • Robert Jurao,
  • Hyung Koo,
  • Michael Proschan,
  • Dean Follmann,
  • H. Clifford Lane

DOI
https://doi.org/10.1097/CCE.0000000000000474
Journal volume & issue
Vol. 3, no. 7
p. e0474

Abstract

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OBJECTIVES:. We sought to validate prognostic scores in coronavirus disease 2019 including National Early Warning Score, Modified Early Warning Score, and age-based modifications, and define their performance characteristics. DESIGN:. We analyzed prospectively collected data from the Adaptive COVID-19 Treatment Trial. National Early Warning Score was collected daily during the trial, Modified Early Warning Score was calculated, and age applied to both scores. We assessed prognostic value for the end points of recovery, mechanical ventilation, and death for score at enrollment, average, and slope of score over the first 48 hours. SETTING:. A multisite international inpatient trial. PATIENTS:. A total of 1,062 adult nonpregnant inpatients with severe coronavirus disease 2019 pneumonia. INTERVENTIONS:. Adaptive COVID-19 Treatment Trial 1 randomized participants to receive remdesivir or placebo. The prognostic value of predictive scores was evaluated in both groups separately to assess for differential performance in the setting of remdesivir treatment. MEASUREMENTS AND MAIN RESULTS:. For mortality, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.60–0.68), and improved with addition of age (c-index, 0.66–0.74). For recovery, baseline National Early Warning Score and Modified Early Warning Score demonstrated somewhat better prognostic ability (c-index, 0.65–0.69); however, National Early Warning Score+age and Modified Early Warning Score+age further improved performance (c-index, 0.68–0.71). For deterioration, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.59–0.69) and improved with addition of age (c-index, 0.63–0.70). All prognostic performance improvements due to addition of age were significant (p < 0.05). CONCLUSIONS:. In the Adaptive COVID-19 Treatment Trial 1 cohort, National Early Warning Score and Modified Early Warning Score demonstrated moderate prognostic performance in patients with severe coronavirus disease 2019, with improvement in predictive ability for National Early Warning Score+age and Modified Early Warning Score+age. Area under receiver operating curve for National Early Warning Score and Modified Early Warning Score improved in patients receiving remdesivir versus placebo early in the pandemic for recovery and mortality. Although these scores are simple and readily obtainable in myriad settings, in our data set, they were insufficiently predictive to completely replace clinical judgment in coronavirus disease 2019 and may serve best as an adjunct to triage, disposition, and resourcing decisions.