Early detection of hospitalized patients with COVID-19 at high risk of clinical deterioration: Utility of emergency department shock index.

BACKGROUND: The COVID-19 outbreak has put an unprecedented strain on Emergency Departments (EDs) and other critical care resources. Early detection of patients that are at high risk of clinical deterioration and require intensive monitoring, is key in ED evaluation and disposition. A rapid and easy risk-stratification tool could aid clinicians in early decision making. The Shock Index (SI: heart rate/systolic blood pressure) proved useful in detecting hemodynamic instability in sepsis and myocardial infarction patients. In this study we aim to determine whether SI is discriminative for ICU admission and in-hospital mortality in COVID-19 patients. METHODS: Retrospective, observational, single-center study. All patients ≥18 years old who were hospitalized with COVID-19 (defined as: positive result on reverse transcription polymerase chain reaction (PCR) test) between March 1, 2020 and December 31, 2020 were included for analysis. Data were collected from electronic medical patient records and stored in a protected database. ED shock index was calculated and analyzed for its discriminative value on in-hospital mortality and ICU admission by a ROC curve analysis. RESULTS: In total, 411 patients were included. Of all patients 249 (61%) were male. ICU admission was observed in 92 patients (22%). Of these, 37 patients (40%) died in the ICU. Total in-hospital mortality was 28% (114 patients). For in-hospital mortality the optimal cut-off SI ≥ 0.86 was not discriminative (AUC 0.49 (95% CI: 0.43-0.56)), with a sensitivity of 12.3% and specificity of 93.6%. For ICU admission the optimal cut-off SI ≥ 0.57 was also not discriminative (AUC 0.56 (95% CI: 0.49-0.62)), with a sensitivity of 78.3% and a specificity of 34.2%. CONCLUSION: In this cohort of patients hospitalized with COVID-19, SI measured at ED presentation was not discriminative for ICU admission and was not useful for early identification of patients at risk of clinical deterioration.

Precarity and pregnancy in Paris.

OBJECTIVE: Our purpose was to assess to what extent the absence of health insurance (Social Security) contributes to poor pregnancy outcome. STUDY DESIGN: A prospective, population-based study compared the perinatal outcome of women without Social Security (n=243) to a contemporaneous control group (n=243) and to a group of women (n=32) with Social Security but presenting another risk factor for precarity (a judicial child-mother separation sentence). RESULTS: Prenatal consultations were less frequent and initiated later for women without Social Security than for controls. There was no difference between these two groups concerning maternal morbidity (premature labour, hypertension, gestational diabetes, post-partum complications) or maternal mortality, no difference for the mode of delivery and the rate of low birth-weight, foetal death, and neonatal morbidity (hypoglycaemia, hypocalcemia, anaemia, jaundice, infection and transfer to intensive care unit). The rate of prematurity was not significantly higher in the group without Social Security compared to the control group (11.1% versus 6.2%, P=0.08). However, in the group with Social Security and a court sentence of child mother separation, the rate of fetal growth retardation, prematurity, home delivery, caesarean section, neonatal drug deprivation syndrome and transfer to an intensive care unit was significantly higher compared to the two other groups (P<0.01). CONCLUSION: In our study, absence of Social Security during pregnancy is not a major determinant of poor pregnancy outcome, whereas other factors of precarity seem to be more influential.