Chest CT in COVID-19 at the ED: Validation of the COVID-19 Reporting and Data System (CO-RADS) and CT Severity Score

Abstract

BackgroundCT is thought to play a key role in coronavirus disease 2019 (COVID-19) diagnostic workup. The possibility of comparing data across different settings depends on the systematic and reproducible manner in which the scans are analyzed and reported. The COVID-19 Reporting and Data System (CO-RADS) and the corresponding CT severity score (CTSS) introduced by the Radiological Society of the Netherlands (NVvR) attempt to do so. However, this system has not been externally validated.Research QuestionWe aimed to prospectively validate the CO-RADS as a COVID-19 diagnostic tool at the ED and to evaluate whether the CTSS is associated with prognosis.Study Design and MethodsWe conducted a prospective, observational study in two tertiary centers in The Netherlands, between March 19 and May 28, 2020. We consecutively included 741 adult patients at the ED with suspected COVID-19, who received a chest CT and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR (PCR). Diagnostic accuracy measures were calculated for CO-RADS, using PCR as reference. Logistic regression was performed for CTSS in relation to hospital admission, ICU admission, and 30-day mortality.ResultsSeven hundred forty-one patients were included. We found an area under the curve (AUC) of 0.91 (CI, 0.89-0.94) for CO-RADS using PCR as reference. The optimal CO-RADS cutoff was 4, with a sensitivity of 89.4% (CI, 84.7-93.0) and specificity of 87.2% (CI, 83.9-89.9). We found a significant association between CTSS and hospital admission, ICU admission, and 30-day mortality; adjusted ORs per point increase in CTSS were 1.19 (CI, 1.09-1.28), 1.23 (1.15-1.32), 1.14 (1.07-1.22), respectively. Intraclass correlation coefficients for CO-RADS and CTSS were 0.94 (0.91-0.96) and 0.82 (0.70-0.90).InterpretationOur findings support the use of CO-RADS and CTSS in triage, diagnosis, and management decisions for patients presenting with possible COVID-19 at the ED. CT is thought to play a key role in coronavirus disease 2019 (COVID-19) diagnostic workup. The possibility of comparing data across different settings depends on the systematic and reproducible manner in which the scans are analyzed and reported. The COVID-19 Reporting and Data System (CO-RADS) and the corresponding CT severity score (CTSS) introduced by the Radiological Society of the Netherlands (NVvR) attempt to do so. However, this system has not been externally validated. We aimed to prospectively validate the CO-RADS as a COVID-19 diagnostic tool at the ED and to evaluate whether the CTSS is associated with prognosis. We conducted a prospective, observational study in two tertiary centers in The Netherlands, between March 19 and May 28, 2020. We consecutively included 741 adult patients at the ED with suspected COVID-19, who received a chest CT and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR (PCR). Diagnostic accuracy measures were calculated for CO-RADS, using PCR as reference. Logistic regression was performed for CTSS in relation to hospital admission, ICU admission, and 30-day mortality. Seven hundred forty-one patients were included. We found an area under the curve (AUC) of 0.91 (CI, 0.89-0.94) for CO-RADS using PCR as reference. The optimal CO-RADS cutoff was 4, with a sensitivity of 89.4% (CI, 84.7-93.0) and specificity of 87.2% (CI, 83.9-89.9). We found a significant association between CTSS and hospital admission, ICU admission, and 30-day mortality; adjusted ORs per point increase in CTSS were 1.19 (CI, 1.09-1.28), 1.23 (1.15-1.32), 1.14 (1.07-1.22), respectively. Intraclass correlation coefficients for CO-RADS and CTSS were 0.94 (0.91-0.96) and 0.82 (0.70-0.90). Our findings support the use of CO-RADS and CTSS in triage, diagnosis, and management decisions for patients presenting with possible COVID-19 at the ED. Take-home PointsResearch Question: We aimed to prospectively validate the coronavirus disease 2019 (COVID-19) Reporting and Data System (CO-RADS) at the ED to be able to compare COVID-19 CT data across different settings and countries. We also evaluated whether the corresponding CT severity score (CTSS) was associated with prognosis.Results: We observed that CO-RADS had an area under the curve compared with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) of 0.91 (CI, 0.89-0.94). After correcting for confounders, the CTSS was significantly positively associated with hospital and ICU admission and mortality. We observed good-to-excellent interobserver agreement for CO-RADS and CTSS and no steep learning curve.Interpretation: Our findings support the use of CO-RADS and CTSS in triage, diagnosis, and management decisions for patients presenting with suspected COVID-19 at the ED.FOR EDITORIAL COMMENT, SEE PAGE 906 Research Question: We aimed to prospectively validate the coronavirus disease 2019 (COVID-19) Reporting and Data System (CO-RADS) at the ED to be able to compare COVID-19 CT data across different settings and countries. We also evaluated whether the corresponding CT severity score (CTSS) was associated with prognosis. Results: We observed that CO-RADS had an area under the curve compared with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) of 0.91 (CI, 0.89-0.94). After correcting for confounders, the CTSS was significantly positively associated with hospital and ICU admission and mortality. We observed good-to-excellent interobserver agreement for CO-RADS and CTSS and no steep learning curve. Interpretation: Our findings support the use of CO-RADS and CTSS in triage, diagnosis, and management decisions for patients presenting with suspected COVID-19 at the ED. FOR EDITORIAL COMMENT, SEE PAGE 906 The coronavirus disease 2019 (COVID-19) pandemic continues to put tremendous stress on health-care systems and societies worldwide. With second waves flaring up globally,1Coronavirus Update (Live)—Worldometers.https://www.worldometers.info/coronavirus/Google Scholar,2Johns Hopkins Coronavirus Resource CenterCOVID-19 Map.https://coronavirus.jhu.edu/map.htmlGoogle Scholar swift and accurate diagnosis is essential to profile patients and allocate scarce resources adequately. This is still hampered by limited sensitivity and availability of severe acute repiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR).3Sethuraman N, Jeremiah SS, Ryo A. Interpreting diagnostic tests for SARS-CoV-2. JAMA. 323(22):2249-2251.Google Scholar, 4Abbasi J. The promise and peril of antibody testing for COVID-19.JAMA. 2020; 323: 1881-1883Crossref PubMed Scopus (147) Google Scholar, 5Wang W. Xu Y. Gao R. et al.Detection of SARS-CoV-2 in different types of clinical specimens.JAMA. 2020; 323: 1843-1844PubMed Google Scholar More importantly, PCR does not give any insight into pulmonary involvement, whereas pneumonia is the most common cause of severe morbidity and mortality in COVID-19.6Zhou F. Yu T. Du R. et al.Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (18962) Google Scholar,7Guan W. Ni Z. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (20519) Google Scholar Chest imaging may play a key role in COVID-19 triage and diagnosis, as well as stratification of disease severity.8Rubin G.D. Haramati L.B. Kanne J.P. et al.The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society.Radiology. 2020; : 201365Crossref PubMed Scopus (638) Google Scholar, 9Simpson S. Kay F.U. Abbara S. et al.Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.J Thorac Imaging. 2020; 35: 219-227Crossref PubMed Scopus (457) Google Scholar, 10Chou R. Pappas M. Buckley D. et al.Use of chest imaging in COVID-19: a rapid advice guide.https://apps.who.int/iris/bitstream/handle/10665/332326/WHO-2019-nCoV-Clinical-Radiology_imaging-Web_Annex_A-2020.1-eng.pdfGoogle Scholar Conventional chest radiography unfortunately has limited sensitivity for COVID-19 pneumonia. In retrospective studies, sensitivity of chest CT for COVID-19 is excellent, and it may even be greater than that of PCR.10Chou R. Pappas M. Buckley D. et al.Use of chest imaging in COVID-19: a rapid advice guide.https://apps.who.int/iris/bitstream/handle/10665/332326/WHO-2019-nCoV-Clinical-Radiology_imaging-Web_Annex_A-2020.1-eng.pdfGoogle Scholar, 11Ai T. Yang Z. Hou H. et al.Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases.Radiology. 2020; 296: E32-E40Crossref PubMed Scopus (3956) Google Scholar, 12Pan F. Ye T. Sun P. et al.Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19).Radiology. 2020; 295: 715-721Crossref PubMed Scopus (1892) Google Scholar CTs are helpful in the diagnostic process at the ED, because the results are available almost immediately, and alternative diagnoses may be identified. In addition, using a semiquantitative CT severity score (CTSS) is reported to correlate with disease severity, and it might be used as a prognostic marker.12Pan F. Ye T. Sun P. et al.Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19).Radiology. 2020; 295: 715-721Crossref PubMed Scopus (1892) Google Scholar, 13Li K. Wu J. Wu F. et al.The clinical and chest CT features associated with severe and critical COVID-19 pneumonia.Invest Radiol. 2020; 55: 327-331Crossref PubMed Scopus (836) Google Scholar, 14Li K. Fang Y. Li W. et al.CT image visual quantitative evaluation and clinical classification of coronavirus disease (COVID-19).Eur Radiol. 2020; 30: 4407-4416Crossref PubMed Scopus (494) Google Scholar, 15Wong H.Y.F. Lam H.Y.S. Fong A.H.-T. et al.Frequency and distribution of chest radiographic findings in COVID-19 positive patients.Radiology. 2020; 296: E72-E78Crossref PubMed Scopus (972) Google Scholar, 16Xiong Y. Sun D. Liu Y. et al.Clinical and high-resolution CT features of the COVID-19 infection: comparison of the initial and follow-up changes.Invest Radiol. 2020; 55: 332-339Crossref PubMed Scopus (323) Google Scholar, 17Liu Z. Jin C. Wu C.C. et al.Association between initial chest CT or clinical features and clinical course in patients with coronavirus disease 2019 pneumonia.Korean J Radiol. 2020; 21: 736-745Crossref PubMed Scopus (50) Google Scholar Studies on using CT as an initial diagnostic modality are mostly retrospective in nature and from China, possibly reducing their generalizability to other regions. the CT characteristics of COVID-19 been no agreement on a systematic and reproducible of and CT in patients with COVID-19, which it to compare data across different G.D. Haramati L.B. Kanne J.P. et al.The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society.Radiology. 2020; : 201365Crossref PubMed Scopus (638) Google S. Kay F.U. Abbara S. et al.Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.J Thorac Imaging. 2020; 35: 219-227Crossref PubMed Scopus (457) Google C. Liu H. Li Y. Liu J. Coronavirus disease 2019 (COVID-19) CT a systematic and Radiol. 2020; Full Text Full Text PDF PubMed Scopus Google Scholar, S. A. S. A. Coronavirus disease 2019 a systematic of imaging findings in J 2020; PubMed Scopus Google Scholar, M. W. T. et a CT for patients with suspected COVID-19: and 2020; 296: PubMed Scopus Google Scholar, J. Z. Li H. et al.CT imaging features of patients with COVID-19: a 2020; PubMed Scopus Google Scholar The Radiological Society of the Netherlands (NVvR) introduced a the COVID-19 Reporting and Data System which is on the of the Radiological Society of North S. Kay F.U. Abbara S. et al.Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA.J Thorac Imaging. 2020; 35: 219-227Crossref PubMed Scopus (457) Google M. W. T. et a CT for patients with suspected COVID-19: and 2020; 296: PubMed Scopus Google M. CO-RADS Scholar The CO-RADS is to be used for patients with to severe of COVID-19. a system from to to pulmonary from to In the found a for COVID-19 under the curve of 0.91 (CI, M. W. T. et a CT for patients with suspected COVID-19: and 2020; 296: PubMed Scopus Google Scholar In addition, interobserver agreement was results are a of the CO-RADS or any other CT classification system for COVID-19 is PCR PCR of and results at in are for PCR polymerase chain SARS-CoV-2 severe acute respiratory syndrome coronavirus in a in are for PCR polymerase chain SARS-CoV-2 severe acute respiratory syndrome coronavirus In this observational to prospectively validate the CO-RADS in two tertiary in The in with from the of chest imaging in Scholar analyzed whether the CTSS was associated with hospital admission, ICU admission, and mortality. This is a prospective, observational were consecutively from the of the two in the Netherlands, between March 19 and May 28, 2020. The study was by the of the was used to for in the patients of and who the ED with suspected COVID-19 to the and for respiratory or of and were were included received a PCR and chest CT with CO-RADS were than to give or a CO-RADS score patients with suspected COVID-19 received a and a chest CT by the or to clinical on of and COVID-19 that a CT in a of to severe of chest imaging in COVID-19 Scholar In a with admission were or respiratory ICU admission were respiratory patients or decisions were not on CT patients with COVID-19 were in a of in respiratory and The on the diagnosis, it was not for the CT The CTs were by with of The had to clinical not to the PCR because CT and were ED admission, PCR results were The of COVID-19 pneumonia was reported to the CO-RADS classification system M. W. T. et a CT for patients with suspected COVID-19: and 2020; 296: PubMed Scopus Google M. CO-RADS Scholar on the CTs were are available in the under pulmonary involvement, CT with a CO-RADS of or was to the Yu et in patients severe acute respiratory evaluation with PubMed Scopus Google Scholar This is a visual of the of disease in The CTSS is the of the and from to or PCR was performed in patients presenting to the ED, to In of a or and clinical of COVID-19, a or PCR was or or available and as by the the area under the and diagnostic accuracy were calculated for calculated the and ORs for hospital admission, ICU admission, and mortality. were by and or by and between were using the or as of was and were reported for of CO-RADS and CTSS was by the area under the curve. The optimal cutoff was by the Diagnostic measures were also a a of with a sensitivity and specificity and specificity were as a of the to a for hospital admission, ICU admission, and mortality. Logistic regression was performed to whether the CTSS score was associated with hospital admission, ICU admission, and 30-day mortality. were by We for the and F. Ye T. Sun P. et al.Time course of lung changes at chest CT during recovery from coronavirus disease 2019 (COVID-19).Radiology. 2020; 295: 715-721Crossref PubMed Scopus (1892) Google Scholar, 13Li K. Wu J. Wu F. et al.The clinical and chest CT features associated with severe and critical COVID-19 pneumonia.Invest Radiol. 2020; 55: 327-331Crossref PubMed Scopus (836) Google Scholar, 14Li K. Fang Y. Li W. et al.CT image visual quantitative evaluation and clinical classification of coronavirus disease (COVID-19).Eur Radiol. 2020; 30: 4407-4416Crossref PubMed Scopus (494) Google Scholar, 15Wong H.Y.F. Lam H.Y.S. Fong A.H.-T. et al.Frequency and distribution of chest radiographic findings in COVID-19 positive patients.Radiology. 2020; 296: E72-E78Crossref PubMed Scopus (972) Google Scholar, 16Xiong Y. Sun D. Liu Y. et al.Clinical and high-resolution CT features of the COVID-19 infection: comparison of the initial and follow-up changes.Invest Radiol. 2020; 55: 332-339Crossref PubMed Scopus (323) Google Scholar, 17Liu Z. Jin C. Wu C.C. et al.Association between initial chest CT or clinical features and clinical course in patients with coronavirus disease 2019 pneumonia.Korean J Radiol. 2020; 21: 736-745Crossref PubMed Scopus (50) Google Scholar agreement was between two acute with and of and the initial the correlation the CT of were used to the learning curve for using CO-RADS for diagnosis of COVID-19. were for patients with a PCR and for patients with a positive PCR In addition, were for accuracy March 19 May 28, patients with COVID-19 at the two Seven hundred forty-one patients the of which had a positive PCR for on the In of the the initial PCR was and PCR testing was to COVID-19. in the were on to hospital admission, or ICU admission, and had a mortality patients were also to as and 2 the distribution of PCR results with the CO-RADS We found that CO-RADS was the optimal cutoff for between a positive and with an of 0.91 (CI, with a sensitivity of 89.4% (CI, specificity of 87.2% (CI, of (CI, and positive of (CI, The correlation was 0.94 (CI, CO-RADS PCR area under the CO-RADS COVID-19 Reporting and Data PCR polymerase chain image for SARS-CoV-2 SARS-CoV-2 COVID-19 Reporting and Data SARS-CoV-2 severe acute respiratory syndrome coronavirus in a CO-RADS COVID-19 Reporting and Data SARS-CoV-2 severe acute respiratory syndrome coronavirus patients had a CT positive with a CO-RADS 2 had a significantly of than with a CO-RADS of had a of than patients were patients received and two patients ICU patients had a CT 4, compared with of patients were still as COVID-19 by the the diagnoses are in The most common alternative diagnoses were pneumonia and The in no or a an was the patient was included to the patient a increase in the The CTSS was in who had a CO-RADS to disease severity from ED, hospital admission, or ICU found a significant in and respectively. Logistic regression a significant positive association between CTSS point and hospital admission, ICU admission, and 30-day mortality significant correcting for and the with adjusted of (CI, 1.23 (CI, and 1.14 (CI, Logistic between score and hospital for severity between score and ICU for between score and 30-day for and of the association between score (CTSS) and hospital admission, ICU admission, and 30-day mortality per point increase in for in a and of the association between score (CTSS) and hospital admission, ICU admission, and 30-day mortality per point increase in hospital admission, the optimal cutoff of the CTSS was with an of (CI, a sensitivity of (CI, and specificity of (CI, ICU admission CTSS had a of (CI, at a cutoff of with a sensitivity of (CI, and specificity of (CI, 30-day CTSS had a of (CI, at a cutoff of with a sensitivity of (CI, and specificity of (CI, that a CTSS was of hospital admission with a specificity of whereas a score of was for ED CTSS was of ICU admission with a specificity of and a score ICU admission with a sensitivity of score of was for 30-day and a score 30-day mortality with a sensitivity of The correlation for the CTSS was 0.82 (CI, this is the study the diagnostic accuracy of chest CT in COVID-19 patients and externally a systematic CT We found that CO-RADS between a positive and PCR with an of 0.91 (CI, 0.89-0.94). We also found that CTSS at ED is associated with hospital admission, ICU admission, and 30-day mortality. The no significant learning curve. In with a interobserver this that the system is to and even for The and associated with a CO-RADS that in the of COVID-19. score of also in patient patient found that almost of the CTs were performed in patients with a of found that chest imaging might be in the of the because it has not the lung T. Yang Z. Hou H. et al.Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases.Radiology. 2020; 296: E32-E40Crossref PubMed Scopus (3956) Google Scholar in the disease course Our results that a CO-RADS score has a positive and a corresponding positive in a was by et T. Yang Z. Hou H. et al.Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases.Radiology. 2020; 296: E32-E40Crossref PubMed Scopus (3956) Google Scholar and et M. W. T. et a CT for patients with suspected COVID-19: and 2020; 296: PubMed Scopus Google Scholar the clinical sensitivity of the PCR in a positive and positive because this N, Jeremiah SS, Ryo A. Interpreting diagnostic tests for SARS-CoV-2. JAMA. 323(22):2249-2251.Google W. Xu Y. Gao R. et al.Detection of SARS-CoV-2 in different types of clinical specimens.JAMA. 2020; 323: 1843-1844PubMed Google Scholar This that specificity of CO-RADS might be In any a CO-RADS to the diagnosis of COVID-19. score of be used to put a patient in or COVID-19 or the of the positive of a CO-RADS study that CT COVID-19 from other with to Z. et of in COVID-19 from pneumonia at chest 2020; 296: PubMed Scopus (836) Google Scholar is to whether CO-RADS is in a with a COVID-19 and a different of other that might on Our results externally validate CO-RADS as a and reproducible tool in pulmonary findings in patients with suspected COVID-19 in a pandemic in the Radiological Society of North America Consensus to during and a for data and CO-RADS CO-RADS be helpful PCR is not available and CT is conducted at the ED on patient as was the in during the The of has CO-RADS in the COVID-19 COVID-19 Scholar Our results that CTSS is positively associated with hospital and ICU admission, and to a mortality even correcting for The positive association of CTSS and hospital or ICU admission is greater than that of mortality. We also observed a for admission than 30-day mortality. This is because the in admission is than in 30-day mortality. are of COVID-19 pulmonary that also mortality and are not by the However, are in of in which the and with a helpful tool to and triage and management and to patient disease because that pulmonary of severe respiratory K. Wu J. Wu F. et al.The clinical and chest CT features associated with severe and critical COVID-19 pneumonia.Invest Radiol. 2020; 55: 327-331Crossref PubMed Scopus (836) Google K. Fang Y. Li W. et al.CT image visual quantitative evaluation and clinical classification of coronavirus disease (COVID-19).Eur Radiol. 2020; 30: 4407-4416Crossref PubMed Scopus (494) Google Scholar the CTSS be helpful in patients that do not on the CTSS might and from admission and a of results are continues the of CT in COVID-19 and CT in their of COVID-19, American and are G.D. Haramati L.B. Kanne J.P. et al.The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society.Radiology. 2020; : 201365Crossref PubMed Scopus (638) Google Scholar, COVID-19 Scholar, College of role of CT in patients suspected with COVID-19 Scholar The consensus statement that the the of CT be a in the of this G.D. Haramati L.B. Kanne J.P. et al.The role of chest imaging in patient management during the COVID-19 pandemic: a multinational consensus statement from the Fleischner Society.Radiology. 2020; : 201365Crossref PubMed Scopus (638) Google Scholar second waves are flaring this is of CT is to in and availability and be an even in countries. of during and to CT We significant in COVID-19 and S. H. A. R. and in the the 2020; PubMed Scopus Google Scholar, and during the COVID-19 2020; Scopus Google Scholar, disease 2019 for and Scholar, et to resources for COVID-19 testing and and 2020; 395: Full Text Full Text PDF PubMed Scopus Google Scholar imaging as lung accuracy than and accuracy to R. Pappas M. Buckley D. et al.Use of chest imaging in COVID-19: a rapid advice guide.https://apps.who.int/iris/bitstream/handle/10665/332326/WHO-2019-nCoV-Clinical-Radiology_imaging-Web_Annex_A-2020.1-eng.pdfGoogle H. S. of lung chest radiography for the diagnosis of adult of the and PubMed Scopus Google Scholar, Y. S. Liu Y. et study on the of of coronavirus pneumonia J. 2020; Scholar, of lung of pneumonia during the Med. 2020; PubMed Scopus Google Scholar, lung in patients with COVID-19: a 2020; PubMed Scopus Google Scholar, et in patients with respiratory a Full Text Full Text PDF PubMed Scopus Google Scholar, D. R. in pneumonia in the a systematic and J Med. 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P. et clinical course and in COVID-19 Med. 2020; PubMed Scopus Google Scholar, T. et for risk stratification in patients with COVID-19: a observational cohort study of 2020; PubMed Scopus Google Scholar, et COVID-19 pneumonia in a pandemic lung CT a prospective, observational study of 2020; PubMed Scopus Google Scholar This may be as a in settings CT might not be Our study has stress that this study was conducted in a CO-RADS was to be used in patients with to severe in this it is CO-RADS the pandemic it is to that the increase in a is to increase disease However, that the for and triage is in a pandemic than in a in which is and resources are not as diagnostic accuracy of CO-RADS and CTSS in a presenting to ED that were to to severe which imaging of the this might to patients in the diagnostic accuracy measures report are of in the After be to tests and alternative diagnoses in patients with severe than are and CO-RADS be in or patients the ED is the is whether this be We the use of CT in the because the possible diagnosis, do not the possible of health-care increase of because of pulmonary in this was the were not of this study were not in whether their patient a CT or The of of patients is In addition, consecutively included a of COVID-19 was because the PCR results were not at the the CT was and the results were from the the CO-RADS and CTSS were by with of However, not learning in the with a this that CO-RADS and CTSS are to use and CO-RADS is an tool to and in diagnosis of COVID-19 in patients with to severe presenting to the ED. the CTSS to correlate with hospital admission, ICU admission, and 30-day and it might be used in management We the use of the CO-RADS and CTSS for patients with of COVID-19 at ED to a for and data We also to be conducted in other and settings to increase the of P. had to of the data in the study and for the of the data and the accuracy of the data and any A. 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