Monitoring

Regularly monitor the following in hospitalized patients to facilitate early recognition of deterioration and monitor for complications:[2][746]

  • Vital signs (temperature, respiratory rate, heart rate, blood pressure, oxygen saturation)

  • Hematologic and biochemistry parameters

  • Coagulation parameters (D-dimer, fibrinogen, platelet count, prothrombin time)

  • ECG

  • Chest imaging

  • Signs and symptoms of venous or arterial thromboembolism.

Medical early warning scores

  • Utilize medical early warning scores that facilitate early recognition and escalation of treatment of deteriorating patients (e.g., National Early Warning Score 2 [NEWS2], Pediatric Early Warning Signs [PEWS]) where possible.[2]

  • There are no data on the value of using these scores in patients with COVID-19 in the primary care setting.[917] 

Pregnant women

  • Monitor vital signs three to four times daily and fetal heart rate in pregnant women with confirmed infection who are symptomatic and admitted to hospital. Perform fetal growth ultrasounds and Doppler assessments to monitor for potential intrauterine growth restriction in pregnant women with confirmed infection who are asymptomatic.[629] Perform fetal growth ultrasound 14 days after resolution of symptoms.[631]

Post-discharge follow-up

  • Patients who are discharged from hospital may have immediate and longer-term health needs including physical (e.g., pulmonary and cardiac rehabilitation, tracheostomy wounds, pressure ulcers, dysphagia, chronic cough, fatigue, neuropathy, muscular weakness, long-term risk of chronic respiratory disorders), psychological and neuropsychological (e.g., delirium, cognitive impairment, post-traumatic stress disorder, anxiety, depression), and social (e.g., impaired activities of daily living).[753]

  • Guidelines for the respiratory follow-up of patients with COVID-19 pneumonia have been published. Follow-up algorithms depend on the severity of pneumonia, and may include clinical consultation and review (face-to-face or telephone) by a doctor or nurse, chest imaging, pulmonary function tests, echocardiogram, sputum sampling, walk test, and assessment of oxygen saturation.[918]

Prognostic scores in development

  • Various prognostic and clinical risk scores are being researched or developed for COVID-19; however, further external validation across various populations is needed before their use can be recommended.

    • A-DROP: a modified version of CURB-65 that showed better accuracy of in-hospital death prediction on admission in patients with COVID-19 pneumonia compared with other widely used community-acquired pneumonia scores.[919]

    • APACHE II: an effective clinical tool to predict hospital mortality that performed better than SOFA and CURB-65 scores in patients with COVID-19. A score of 17 or more is an early indicator of death and may help provide guidance to make further clinical decisions.[920]

    • CALL: a risk factor scoring system that scores patients based on four factors: comorbidities, age, lymphocyte count, and lactate dehydrogenase level. One study found that 96% of patients with low CALL scores did not progress to severe disease.[921] 

    • COVID-GRAM: a web-based calculator that estimates the probability that a patient will develop critical illness and relies on the following 10 variables at admission: chest radiographic abnormality, age, hemoptysis, dyspnea, unconsciousness, number of comorbidities, cancer history, neutrophil-to-lymphocyte ratio, lactate dehydrogenase, and direct bilirubin. Additional validation studies, especially outside of China, are required.[922] 

    • COVID-19MRS: a rapid, operator-independent clinical tool that was found to objectively predict mortality in one retrospective cohort study.[923]

    • 3F: a mortality prediction model based on three clinical features: age, minimum oxygen saturation, and type of patient encounter (i.e., inpatient vs outpatient and telehealth encounters). One study found that the model showed high accuracy when applied to retrospective and prospective data sets of COVID-19 patients.[924]

    • 4C: a score developed and validated in a UK prospective cohort study of adults admitted to hospital with COVID-19. The score uses patient demographics, clinical observations, and blood parameters commonly available at the time of hospital admission, and can accurately characterize patients as being at low, intermediate, high, or very high risk of death. The score outperformed other risk stratification tools, showed clinical decision-making utility, and had similar performance to more complex models.[925]

    • QCOVID: a novel clinical risk prediction algorithm to estimate the risk of hospital admission and mortality based on age, ethnicity, deprivation, body mass index, and a range of comorbidities. A population-based cohort study found that the algorithm performed well, showing very high levels of discrimination for deaths and hospital admissions.[926]

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