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The PRIEST Study:

Pandemic Respiratory Infection Emergency System Triage

Background

Respiratory infections, such as influenza or the corona virus, affect the lungs and airways, causing symptoms including fever, sore throat, coughing and breathing difficulties. If a new strain of the virus becomes widespread across many countries, this can be classified as a pandemic. During a pandemic, more patients attend hospital services and require investigation or admission, which puts a huge strain on the NHS.

Patients who contact emergency services (via NHS 111, 999 ambulance services or emergency departments) with a suspected pandemic respiratory infection need to be rapidly assessed to determine the severity of their illness, and whether they need to be admitted to hospital. This process is called "triage". Triage often uses methods such as scores or decision rules. These have been developed and are ready for use in a pandemic, but we don’t know how well they can correctly predict who needs to be admitted to hospital, and who does not.

Research Objectives

We aim to:

  • Optimise the triage of people using the emergency care system with suspected respiratory infections during a pandemic
  •  Identify the most accurate triage method for predicting severe illness among patients attending the emergency department with suspected respiratory infection

Our specific objectives after the pandemic are:

  1. To determine the discriminant value of emergency department triage methods for predicting severe illness in patients presenting with suspected pandemic respiratory infection
  2. To determine the discriminant value of presenting clinical characteristics and routine tests for identifying severe illness
  3. To determine the independent predictive value of presenting clinical characteristics and routine tests for severe illness
  4. To develop new triage methods based upon presenting clinical characteristics alone or presenting clinical characteristics, electrocardiogram (ECG), chest X-ray and routine blood test results, depending upon the data available and the predictive value of variables evaluated in objective 3

The PRIEST Study Method

The PRIEST study uses patient data from the early phases of a respiratory infection pandemic, such as COVID-19, to test how well existing triage methods predict serious complications. The study will also identify cases where the triage methods did not predict serious complications or recommended unnecessary hospital admission, and where possible modify triage methods or develop new triage methods that predict serious complications better than existing methods.

To do this, during a respiratory infection pandemic, we will be recording medical details in a standardised way from patients with suspected respiratory infection using a triage form. We will then use hospital records to follow these patients up to 30 days on to find out if they die or suffer a life-threatening complication.

We will evaluate triage methods used to determine whether a patient with suspected pandemic respiratory infection should be admitted to hospital or not, and whether they should be admitted to intensive or high dependency care. These may include the CURB-65 score, PMEWS, the swine flu hospital pathway, SMART-COP, the SwiFT score and any new methods developed before the next pandemic. We will also develop two new triage methods based upon (a) presenting clinical characteristics alone and (b) presenting clinical characteristics, electrocardiogram (ECG), chest X-ray and routine blood test results.

The results of this study can be used in the following stages of the pandemic, to produce a guideline or rule to help decide which patients would benefit from being admitted to hospital. The findings can also help doctors and nurses identify which individual patients may go on to develop serious complications. We may also be able to identify which patient characteristics are associated with a higher risk of serious complications, such as age or underlying health conditions. For example, in the 2009 influenza pandemic, it was found that pregnant patients, and those suffering from obesity, were at higher risk of developing complications.

Characteristics of people attending the emergency department with suspected COVID-19

The PRIEST study has collected data from 13783 people attending emergency departments in the UK, as of 14 May 2020. We provide a brief overview of the characteristics of the cohort to date. These are interim data, intended to assist those responsible for delivering emergency department care during the ongoing pandemic. Definitive findings (including outcome data) will be published in due course.

The cohort currently has a mean age of 59 years, 6791 (49.3%) are female and 6845 (49.7%) are male. The most common symptoms are shortness of breath 9824 (71.3%), cough 8525 (61.9%) and fever 7271 (52.8%). Some 2660 (19.3%) of the cohort have previous heart disease, 1121 (8.1%) have renal impairment, 2097 (15.2%) have asthma, 2077 (15.1%) have another chronic lung disease, 3798 (27.6%) have hypertension, 2462 (17.9%) have diabetes, 646 (4.7%) have active malignancy, 394 (2.9%) are immunosuppressed, 304 (2.2%) are receiving steroid therapy and 3561 (25.8%) have no long-term medical conditions recorded.

COVID-19 was considered to be the most likely diagnosis in 9230 (67.0%) of the cohort during emergency department assessment.

The figure below shows the NEWS2 scores for the 13392 patients for whom the score could be calculated.

Figure showing NEWS2 Scores

Patient Information

The risks to patients involved in this study are very low, because the project will not involve any change to the way patients are assessed or treated. Information will be gathered in a way that aims to help doctors and nurses, and does not interfere with patient care. The way we collect information about patients has been tested during a winter flu season to confirm this.

Most personal details will be removed from information that leaves a hospital. We are only recording NHS numbers and ambulance incident numbers so that we can track how patients move through NHS services. Identifiable information, such as patient’s names, will only be available to hospital staff.

We will not be asking patients for written consent to use their data in the study because this could cause delays, which may be harmful in a pandemic. However, we will inform patients of the study, and let them know that they can remove their data if they wish.

Patients can contact one of the hospitals involved in the study to ask for their information to be removed from the study. This approach has worked well in previous studies, and was approved by an independent Research Ethics Committee and the Confidentiality Advisory Group of the Health Research Authority. If you are included in the study at a hospital a member of hospital staff will hand you an information leaflet ways you can opt out at the time, either by filling out the leaflet and handing it back or by contacting a local member of the research team.

For more information on your rights in the study please got to our PRIEST Privacy Notice.

Funder

This project is funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 16/80/08). Any views or opinions expressed are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

Study Team

Name Site Role Phone Email
Professor Steve Goodacre ScHARR Chief Investigator +44 (0)114 222 0842 s.goodacre@sheffield.ac.uk
Dr Benjamin Thomas ScHARR Study Manager +44 (0)114 22 24024 b.d.thomas@sheffield.ac.uk
Katie Biggs ScHARR CTRU Oversight +44 (0)114 22 26128 c.e.biggs@sheffield.ac.uk
Ellen Lee ScHARR Statistician +44 (0) 114 222 0805 e.lee@sheffield.ac.uk
Amanda Loban ScHARR Data Management +44 (0) 114 222 2995 a.loban@sheffield.ac.uk

Project Management Group

Name Site Role Phone Email
Dr Kirsty Challen Lancashire Teaching Hospitals NHS Foundation Trust Consultant in Emergency Medicine kirsty.challen@lthtr.nhs.uk
Dr Andrew Bentley University Hospital of South Manchester Critical Care Expertise +44 (0)161 291 6420 andrew.bentley@manchester.ac.uk
Dr Darren Walter University Hospital of South Manchester Expert in Pandemic Emergency Planning +44 (0)161 291 6047 darren.walter@manchester.ac.uk
Dr Ian Maconochie St Mary's Hospital, London Expert in Paediatric Emergency Medicine +44 (0)207 886 6139 i.maconochie@imperial.ac.uk
Dr Chris Fitzsimmons Sheffield Children's Hospital Expert in Paediatric Emergency Medicine +44 (0)114 271 7431 c.fitzsimmons@nhs.net
Andrew Lee ScHARR, The University of Sheffield Senior Clinical University Teacher +44 (0)114 222 0872 andrew.lee@sheffield.ac.uk
Fiona Lecky ScHARR, The University of Sheffield Principle Investigator +44 (0)114 222 0834 f.e.lecky@sheffield.ac.uk
Tim Harris Barts Health NHS Trust Principle Investigator tim.harris@bartshealth.nhs.uk

Sites

Site PI
Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital Professor Steve Goodacre
Sheffield Children's NHS Foundation Trust, Sheffield Children's Hospital Chris Fitzsimmons
Salford Royal NHS Foundation Trust, Salford Royal Hospital Fiona Lecky
York Teaching Hospital NHS Foundation Trust, York Hospital Joanne Ingham
York Teaching Hospital NHS Foundation Trust, Scarborough General Hospital Dr Richard Smith
King's College Hospital NHS Foundation Trust, King's College Hospital Fleur Cantle
Barnsley Hospital NHS Foundation Trust, Barnsley Hospital Professor Suzanne Mason
University Hospitals Plymouth NHS Trust, Derriford Hospital Dr Simon Horne
Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital Dr Liza Keating
Dorset county Hospital NHS Foundation Trust, Dorset County Hospital Dr Tamsin Ribbons
Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire Royal Hospital Tanya De Weymarn
The Royal Wolverhampton NHs Trust, New Cross Hospital Jagtar Pooni
The Shrewsbury & Telford Hospital NHS Trust, Princess Royal Hospital and Royal Shrewsbury Hospital Dr Adrian Marsh
University Hospital North Midlands NHS Trust, Royal Stoke Hospital Dr Mark Harrison
Southend University Hospital NHS Foundation Trust, Southend Hospital Bernard Hadebe
Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital Dr Melanie Darwent
NHS Lothian, Royal Infirmary of Edinburgh Dr Alasdair Gray
Mid and South Essex NHS Foundation Trust, Broomfield Hospital Dr Steve Jenkins
Newcastle upon Tyne Hospitals NHS Trust, Royal Victoria Infirmary Dr John Wright
Manchester University NHs Foundation Trust, Manchester Royal Infirmary and Royal Manchester Children's Hospital Dr Rick Body
Liverpool University Hospitals NHS Foundation Trust, Aintree University Hospital Dr Abdo Sattout
Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital Adrian Boyle
Nottingham University Hospitals NHS Trust, Queen's Medical Centre Dr Frank Coffey
Northern Ireland, Craigavon Area Hospital Lesley Ann Funston
Aneurin Bevan University Health Board, Royal Gwent Hospital and Nevill Hall Hospital Dr Ashkok Vaghela
The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, Queen Elizabeth Hospital Dr Nam Tong
Kings College Hospital NHS Foundation Trust, King's College Hospital Dr Rob Pinate
Ashford and St Peter's Hospital NHS Foundation Trust, Ashford Hospital and St Pater's Hospital Dr Jessica Law
Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital Dr Kirsty Challen
North Tees and Hartlepool Foundation Trust Ignacio Cardona
Epsom and St Helier University Hospitals NHS Trust, Epsom Hospital and St Helier Hospital Rebecca MacFarlane
Bart's Health NHS Trust, St Bartholomew's Hospital Ben Bloom
Hull University Teaching Hospitals NHS Trust, Hull Royal Infirmary William Townend
Great Western Hospitals NHS Foundation Trust, Great Western Hospital Suzannah Pegler
County Durham and Darlington NHS Foundation Trust Amanda Cowton
St George's University Hospital NHS Foundation Trust, St George's Hospital Heather Jarman
South Tees Hospitals NHS Foundation Trust, The James Cook Unviersity Hospital David Chadwick
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Royal Bournemouth Hospital Laura Purandare
Sherwood Forest Hospital NHS Foundation Trust Jill Woodhead
East Sussex Healthcare NHS Trust Shaymau Habeeb
Bolton NHS Foundation Trust, Royal Bolton Hospital Richard Parris
Surrey and Sussex Healthcare Foundation Trust, East Surrey Hospital Christine Dixon
Lewisham and Greenwich NHS Trust Hannah Kelly
East Lancashire Hospital NHS Trust, Royal Blackburn Teaching Hospital Raj Garlapati