General surgeon, 411th HC FWD.
Physician, 3D MCDS.
Med J (Ft Sam Houst Tex). 2021 Jan-Mar(PB 8-21-01/02/03):150-155.
The COVID-19 pandemic poses unique challenges within the austere clinical setting, and the time between patient presentation and deterioration is a critical opportunity for intervention. In some cases, this may be a life-saving transfer to a higher level of care. US Central Command (CENTCOM) has provided valuable guidance for COVID-19 management in the operational environment,1 and has proposed the National Early Warning System 2 (NEWS2) scoring tool as a useful adjunct to gauging illness severity. NEWS2, however, does not consider co-morbidities, such as diabetes or chronic cardiac disease, which could worsen the clinical course of SARS-CoV-2 patients. Thus, NEWS2 fails to address such factors during the risk stratification of patients to a higher level of care. To address this concern, June 2020, 3rd Medical Brigade, Operation Spartan Shield (OSS) developed the COVID-19 Army Rapid Assessment Tool (CARAT) with inputs from clinicians and researchers (The Team). The CARAT is a clinical scoring system, modified from the NEWS2, which combines the effects of co-morbid disease with the current physiological condition of a COVID-19 patient. The Team obtained clinical data for 105 patients from the CENTCOM area of responsibility (AOR), who presented to a military treatment facility (MTF) symptomatic for, and testing positive for SARS-CoV-2, during the time period of June to mid-August 2020. Each patient was retrospectively assigned a CARAT score based on his or her initial presentation. Preliminary review of data suggested a CARAT value of 4 or greater was an indicator for risk of further deterioration. Patients were then grouped into two categories: patients who received transfer to a higher level of care, versus "stay-in-place" supportive care. Results showed that 100% of patients with a score ≥4 had been transferred to a higher echelon of care, compared to 2% of patients with scores less than 4. A Fisher's exact test demonstrated a statistically significant difference between these two groups (p is less than 0.001). Interestingly, when compared with the NEWS2 score, the CARAT identified 9 individuals for transfer to a higher level of care, of whom only one patient was identified by the NEWS2, clearly underscoring the significance of CARAT despite small sample size. We therefore recommend that CARAT be further validated in predicting disease severity and need for emergent evacuation in larger patient settings.
COVID-19 大流行在严峻的临床环境中带来了独特的挑战，从患者出现症状到病情恶化的这段时间是进行干预的关键机会。在某些情况下，这可能是将患者转移到更高水平的治疗的救命之举。美国中央司令部（CENTCOM）为作战环境中的 COVID-19 管理提供了宝贵的指导，1 并提出了国家早期预警系统 2（NEWS2）评分工具，作为评估疾病严重程度的有用辅助手段。然而，NEWS2 并未考虑糖尿病或慢性心脏疾病等合并症，这些疾病可能会使 SARS-CoV-2 患者的临床病程恶化。因此，NEWS2 在对更高水平的治疗患者进行风险分层时未能考虑这些因素。为了解决这一问题，2020 年 6 月，第 3 医疗旅，斯巴达盾牌行动（OSS）与临床医生和研究人员（团队）合作，开发了 COVID-19 陆军快速评估工具（CARAT）。CARAT 是一种临床评分系统，是对 NEWS2 的修改，将合并症的影响与 COVID-19 患者的当前生理状况结合起来。该团队从 CENTCOM 责任区（AOR）获得了 105 名患者的临床数据，这些患者在 2020 年 6 月至 8 月中旬期间因出现症状且 SARS-CoV-2 检测呈阳性而到军事治疗设施（MTF）就诊。每位患者根据其最初的就诊情况被回溯性地分配了一个 CARAT 评分。对数据的初步审查表明，CARAT 值为 4 或更高是病情进一步恶化的风险指标。然后将患者分为两组：转移到更高水平的治疗的患者，和“就地”支持性护理的患者。结果显示，100%的 CARAT 值≥4 的患者已被转移到更高的医疗层级，而 CARAT 值<4 的患者只有 2%。Fisher 确切检验显示这两组之间存在统计学显著差异（p 值小于 0.001）。有趣的是，与 NEWS2 评分相比，CARAT 识别出 9 名需要转移到更高水平的治疗的患者，其中只有 1 名患者被 NEWS2 识别，这清楚地表明了 CARAT 的重要性，尽管样本量较小。因此，我们建议在更大的患者群体中进一步验证 CARAT 以预测疾病严重程度和紧急疏散的需求。
