4C Mortality Score for COVID-19
Validated prognostic score predicting in-hospital mortality in adults hospitalised with COVID-19. Uses 8 readily available clinical variables at admission. Validated in multiple national and international cohorts.
Score interpretation
4C low risk -- very low probability of in-hospital mortality from COVID-19
→ Consider outpatient or early discharge pathway (with safety netting); monitor SpO2 at home (alert return if SpO2 < 94% or rapid decline); antipyretics and symptomatic management; ensure vaccination status reviewed; antivirals: nirmatrelvir-ritonavir (Paxlovid) or sotrovimab if high-risk immunocompromised patient (NICE COVID therapeutics; refer via COVID Medicines Delivery Unit); no specific antiviral for low-risk admitted patients; dexamethasone NOT indicated unless requiring supplemental O2.
4C intermediate risk -- moderate mortality probability; active inpatient management
→ Inpatient admission; supplemental O2 if SpO2 < 92%; dexamethasone 6 mg OD x10 days if requiring supplemental oxygen (RECOVERY trial -- 35% mortality reduction); remdesivir 200 mg IV day 1 then 100 mg IV days 2-5 if SpO2 <= 94% requiring supplemental O2 (EMA approved); baricitinib 4 mg OD x14 days if on O2 + dexamethasone (RECOVERY, COV-BARRIER trials); VTE prophylaxis (therapeutic or prophylactic based on D-dimer/risk); prone awake positioning if tolerated; NEWS2 monitoring; escalation criteria pre-agreed (ICU if RR > 30, SpO2 < 90 on O2, or haemodynamic compromise).
4C high or very high risk -- high in-hospital mortality; intensive management and escalation planning
→ Senior review and ICU/HDU consideration; high-flow nasal oxygen (HFNO) 40-60 L/min or CPAP 5-10 cmH2O for moderate-severe hypoxaemic respiratory failure; dexamethasone 6 mg OD x10 days; baricitinib 4 mg OD; remdesivir if within 10 days of symptom onset and not on invasive ventilation; intubation and invasive ventilation if: RR > 35, PaO2/FiO2 < 100, signs of fatigue; lung-protective ventilation (6 mL/kg IBW, plateau pressure < 30 cmH2O); prone ventilation > 12 hours/day (PROSEVA, RECOVERY-RS); VTE: therapeutic anticoagulation for IMV patients (ACTIV-4a: therapeutic superior to prophylactic in non-critical); ECMO if severe refractory ARDS; goals of care discussion; DNACPRconsideration; palliative care early involvement for very high risk patients.
Interpretation bands for the 4C Mortality Score. Apply clinical judgement and local guidance.
References
- Knight SR et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ. 2020;370:m3339.
- NICE COVID-19 rapid guideline: managing COVID-19. NICE NG191. 2021 (updated 2023).
Related
Curated clinical cross-links plus same-class fallbacks.
- Dexamethasone (ICU / ARDS) · Systemic Corticosteroid
- Tocilizumab (ICU — Cytokine Storm / COVID-19) · IL-6 Receptor Inhibitor
- Dexamethasone · Potent Systemic Corticosteroid
- Acetic Acid 2% (Ear Drops) · Topical antibacterial / Antifungal (ear)
- Dexamethasone · Corticosteroid — ENT Inflammation / Croup
- Framycetin / Sofradex · Topical Antibiotic-Steroid — Otitis Externa
- Major Haemorrhage / Massive Transfusion · BCSH; RCOA; RCEM; RCS — BCSH Guidelines
- Anaemia Investigation · BSH / NICE
- Splenomegaly Workup · BSH; BMJ Best Practice
- Deep Vein Thrombosis Diagnosis and Treatment · NICE CG144 / NICE NG158
- Sickle Cell Crisis · BSH 2021 / BCSH
- Neutropenic Sepsis · NICE CG151 2012 / ESMO
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.