BackgroundThe SARS-CoV-2 virus responsible for COVID-19 poses a significant challenge to healthcare systems worldwide. Despite governmental initiatives aimed at containing the spread of the disease, several countries are experiencing unmanageable increases in the demand for ICU beds, medical equipment, and larger testing capacity. Efficient COVID-19 diagnosis enables healthcare systems to provide better care for patients while protecting caregivers from the disease. However, many countries are constrained by the limited amount of test kits available, lack of equipment and trained professionals. In the case of patients visiting emergency rooms (ERs) with a suspect of COVID-19, prompt diagnosis may improve the outcome and even provide information for efficient hospital management. In such a context, a quick, inexpensive and readily available test to perform an initial triage in ERs could help to smooth patient flow, provide better patient care, and reduce the backlog of exams.MethodsIn this Case-control quantitative study, we developed a strategy backed by artificial intelligence to perform an initial screening of suspect COVID-19 patients. We developed a machine learning classifier that takes widely available simple blood exams as input and classifies samples as likely to be positive (having SARS-CoV-2) or negative (not having SARS-CoV-2). Based on this initial classification, positive cases can be referred for further highly sensitive testing (e.g. CT scan, or specific antibodies). We used publicly available data from the Albert Einstein Hospital in Brazil from 5,644 patients. Focusing on simple blood exam figures as main predictors, a sample of 599 subjects that had the fewest missing values for 16 common exams were selected. From these 599 patients, 81 tested positive for SARS-CoV-2 (determined by RT-PCR). Based on the reduced dataset, we built an artificial intelligence classification framework, ER-CoV, aiming at determining if suspect patients arriving in ER were likely to be negative for SARS-CoV-2, that is, to predict if that suspect patient is negative for COVID-19. The primary goal of this investigation is to develop a classifier with high specificity and high negative predictive values, with reasonable sensitivity.FindingsWe identified that our AI framework achieved an average specificity of 85.98% [95%CI: 84.94 – 86.84] and negative predictive value (NPV) of 94.92% [95%CI: 94.37% – 95.37%]. Those values are completely aligned with our goal of providing an effective low-cost system to triage suspect patients in ERs. As for sensitivity, our model achieved an average of 70.25% [95%CI: 66.57% – 73.12%] and positive predictive value (PPV) of 44.96% [95%CI: 43.15% – 46.87%]. The area under the curve (AUC) of the receiver operating characteristic (ROC) was 86.78% [95%CI: 85.65% – 87.90%]. An error analysis (inspection of which patients were misclassified) identified that, on average, 28% of the false negative results would have been hospitalized anyway; thus the model is making mistakes for severe cases that would not be overlooked, partially mitigating the fact that the test is not highly sensitive. All code for our AI model, called ER-CoV is publicly available at https://github.com/soares-f/ER-CoV.InterpretationBased on the capacity of our model to accurately predict which cases are negative from suspect patients arriving in emergency rooms, we envision that this framework may play an important role in patient triage. Probably the most important outcome is related to testing availability, which at this point is extremely low in many countries. Considering the achieved specificity, we could reduce by at least 90% the number of SARS-CoV-2 tests performed in emergency rooms, with around 5% chance of getting a false negative. The second important outcome is related to patient management in hospitals. Patients predicted as positive by our framework could be immediately separated from other patients while waiting for the results of confirmatory tests. This could reduce the spread rate within hospitals since in many of them all suspect cases are kept in the same ward. In Brazil, where the data was collected, rate infection is starting to quickly spread and the lead time of a SARS-CoV-2 may be up to 2 weeks.FundingThe University of Sheffield provided financial support for the Ph.D. scholarship for Felipe SoaresProf. Fogliatto’s research is funded by CNPq [Grant # 303509/2015-5].Prof. Anzanello’s research is funded by CNPq [Grant # 306724/2018-9].
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