Brescia-COVID Respiratory Severity Scale (BCRSS)/Algorithm

Why Use

This score uses both patient exam features as well as need for escalating levels of respiratory support (NIV, intubation, proning) to recommend increasing treatment recommendations. It drastically simplifies the clinical summary of a patient’s status and makes it incredibly easy to compare patients to one another as well as to trend patients’ levels over time. It also allows healthcare workers to monitor patients nearing a critical action point more closely (example: Level 3, possibly nearing the need for intubation).

When to Use

In Italy, this score is being used in patients who have COVID-19 pneumonia OR have had COVID-19 symptoms for ≥7 days AND are either PCR+ OR high clinical suspicion for COVID-19. This is used for every single patient with these diagnoses and is critical in the hospital in Brescia, Italy where it was developed to compare and quickly summarize a patient’s clinical severity during this pandemic.

Formula

Pearls / Pitfalls

This score was rapidly developed in Italy during their COVID-19 crisis and has not been validated or tested in other populations; it was also developed while the world is still learning more daily about COVID-19. Doctors in Brescia are referring to these patients mostly by number, and in the ICU these patients have their assigned level taped above their beds, which is updated daily. This score is meant to be dynamic and frequently reassessed and re-scored after interventions; frequency of reassessment is by clinical judgment. A brand new patient in the ED may need to be reassessed every 15 minutes, for example, while a stable patient on the medical floor may only need reassessment every 6-12 hours. If a patient is assigned a new score based on these criteria, the medical and respiratory management should then change as well. Patients are also assigned a sub-score using daily CXR findings to help stratify patients further; 3 quadrants of each lung are each assigned a score, 0-3, with zero points showing no opacification, 3 points being full opacification of the lung quadrant, and these points are then tallied. For example, a patient at “Level 3 with 12 points on CXR” would be much more serious than a patient at “Level 3 with 2 points on CXR.” Note: While many in North America have raised concerns about risk of viral particle spread from NIV/HFNC and healthcare worker exposure, Italian doctors included these ventilation strategies in their pathways because they simply do not have enough ventilators to accommodate all the patients and the only other alternative for these patients would be death.

Management

This score is meant to be dynamic and frequently reassessed and re-scored after interventions; frequency of reassessment is by clinical judgment. A brand new patient in the ED may need to be reassessed every 15 minutes, for example, while a stable patient on the medical floor may only need reassessment every 6-12 hours. If a patient is assigned a new score based on these criteria, the medical and respiratory management should then change as well.

Critical Actions

Patients requiring significant levels of oxygen, tachypnea, or ventilatory support are obviously at extremely high risk for clinical decompensation and death.

Advice

Healthcare workers must be aware that COVID-19 information is rapidly changing; MDCalc will attempt to update this score as frequently as possible to keep up with the rapidly changing nature of this pandemic. While this score certainly would indicate increasing levels of respiratory severity, one's local hospital recommendations or drug availability may provide different recommendations for treatment.