• Fulvio Morello, Paolo Bima, Jacopo D Giamello, Denise Baricocchi, Francesca Risi, Matteo Vesan, Emanuele E Pivetta, Giuliano de Stefano, Michela Chiarlo, Simona Veglia, Giulia Schivazappa, Giulio Mengozzi, Giuseppe Lauria, Stefano Podio, Peiman Nazerian, Franco Aprà, Enrico Ferreri, Enrico Lupia, and CODED Study Investigators.
• Emergency Medicine U Unit, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy - fulvio.morello@unito.it.
• Minerva Med. 2022 Dec 1; 113 (6): 916926916-926.

BackgroundFor COVID-19 patients evaluated in the Emergency Department (ED), decision on hospital admission vs. home discharge is challenging. The 4C mortality score (4CMS) is a prognostication tool integrating key demographic/clinical/biochemical data validated for COVID-19 inpatients. We sought to derive and validate a dichotomic rule based on 4CMS identifying patients with mild outcomes, suitable for safe ED discharge.MethodsDerivation was performed in a prospective cohort of ED patients with suspected COVID-19 from two centers (April 2020). Validation was pursued in a prospective multicenter cohort of ED patients with confirmed COVID-19 from 6 centers (October 2020 to January 2021). Chest X-ray (CXR) images were independently scored. The primary composite outcome was all-cause 30-day mortality or hospital admission. Secondary outcomes were ED re-visit, oxygen therapy and ventilation.ResultsIn a derivation cohort of 838 ED patients with suspected COVID-19, 4CMS≤8 was associated with low outpatient mortality (0.4%) and was thus selected as a feasible discharge rule. In a validation cohort of 521 COVID-19 outpatients, the mean age was 51±17 years; 97 (18.6%) patients had ≥1 CXR infiltrate. The 4CMS had an AUC of 0.82 for the primary outcome and 0.93 for mortality, outperforming other scores (CURB-65, qCSI, qSOFA, NEWS) and CXR. In 474 (91%) patients with 4CMS≤8, the mortality rate was 0.2% and the hospital admission rate was 6.8%, versus 12.8% and 36.2% for 4CMS≥9 (P<0.001). CXR did not provide additional discrimination.ConclusionsCOVID-19 outpatients with 4CMS≤8 have mild outcomes and can be safely discharged from the ED. [NCT0462918].

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