LAUSR

The COVID-19 pandemic has been associated with global surges in need for hospital-based and other healthcare resources, as well as shortages in vital items such as ICU beds, mechanical ventilators, and personal protective equipment (Fig. 1) (1). During the initial waves of the COVID-19 pandemic, several countries experienced a shortage of mechanical ventilators (2). Decision-making on triage and rationing of scarce resources during a crisis can lead to critical adjustments to what would otherwise be considered standard of care. For patients who are fully ventilator-dependent, decisions surrounding initiation or termination of mechanical ventilation can acutely mean the difference between life and death (2). Although health system surge capacities (both for acute and routine care needs) can be essential to pandemic preparedness (1), it is also of paramount importance that policies on crisis standards of care be informed by both evidence and ongoing reevaluation. In this issue of Critical Care Medicine, Keller at al (3) provide key insights regarding the use of a preintubation Sequential Organ Failure Assessment (SOFA) score to predict COVID-19 mortality. In a multicenter, retrospective, large database cohort study of over 15,000 mechanically ventilated COVID-19 patients at 86 U.S. healthcare systems, the authors used electronic health record data to assess the predictive capacity of the SOFA score for inhospital mortality in COVID-19 patients. The authors found that the SOFA score demonstrated poor discriminant accuracy for inhospital mortality in mechanically ventilated patients. The observed area under the receiver operating curve (AUC) for the SOFA score to predict inhospital mortality was 0.66 (95% CI, 0.65–0.67), generally considered poor accuracy (the authors used the cutoffs of less than 0.7 as poor accuracy, 0.7–0.8 as moderate, 0.8–0.9 as good, and greater than 0.9 as excellent) (4). The addition of comorbidities did not substantially improve the predictive model, and age alone performed better for predicting inhospital mortality than the SOFA score. Even when reviewing ventilated patients with COVID-19 who survived hospitalization, the SOFA score poorly predicted those who required long-term acute care. This study adds notable value for several reasons. The findings add multiinstitutional external validity, with a large sample size, to an increasing number of smaller studies questioning the utility of using the SOFA score in this context (5, 6). In a 2021 research letter published in JAMA, Raschke et al (5) conducted a retrospective review of 675 adult patients with COVID pneumonia requiring mechanical ventilation across 18 ICUs in the southwestern United States. Similar to the findings from Keller et al (3), the authors of the JAMA research letter found poor discriminant accuracy for the SOFA score Claudia L. Sotillo, MD1