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Trends in ICU Mortality From Coronavirus Disease 2019: A Tale of Three Surges
Sara C Auld1,2,3,4,5,6,7,8,9, Kristin R V Harrington3, Max W Adelman4
1Emory Critical Care Center (ECCC), Atlanta, GA.
Insights
Hospital mortality for critically ill coronavirus disease 2019 patients was highest during the fall and winter of 2020. This increased risk was associated with later periods of the pandemic, despite evolving treatments.
Area of Science:
- Critical Care Medicine
- Infectious Diseases
- Epidemiology
Background:
- Coronavirus disease 2019 (COVID-19) presented a significant challenge to healthcare systems globally.
- Understanding temporal trends in outcomes for critically ill patients is crucial for resource allocation and treatment strategies.
Purpose of the Study:
- To investigate the association between the time period of hospitalization and hospital mortality among critically ill adults with COVID-19.
- To identify specific periods of increased mortality risk during the pandemic.
Main Methods:
- An observational cohort study was conducted from March 2020 to January 2021, involving 1,686 adult patients admitted to intensive care units (ICUs) across four hospitals.
- Patients were categorized into distinct pandemic phases: Surge 1, Lull 1, Surge 2, Lull 2, and Surge 3.
- Statistical analyses adjusted for baseline risk factors and clinical status at ICU admission to determine the relative risk of mortality.
Main Results:
- Overall hospital mortality was 29.7%, with significant variations across pandemic periods (p = 0.007).
- Mortality rates were 28.7% (Surge 1), 21.3% (Lull 1), 25.2% (Surge 2), 30.2% (Lull 2), and 34.7% (Surge 3).
- Increased mortality risk was associated with later pandemic periods, specifically Lull 2 (RR, 1.37) and Surge 3 (RR, 1.35), compared to Surge 1, after adjusting for covariates.
Conclusions:
- Despite advancements in care and treatments for COVID-19, the risk of death for ICU patients was highest during the fall and winter of 2020.
- The reasons for this elevated mortality during specific later pandemic periods remain unclear and warrant further investigation.
Objectives:
To determine the association between time period of hospitalization and hospital mortality among critically ill adults with coronavirus disease 2019.
Design:
Observational cohort study from March 6, 2020, to January 31, 2021.
Setting:
ICUs at four hospitals within an academic health center network in Atlanta, GA.
Patients:
Adults greater than or equal to 18 years with coronavirus disease 2019 admitted to an ICU during the study period (i.e., Surge 1: March to April, Lull 1: May to June, Surge 2: July to August, Lull 2: September to November, Surge 3: December to January).
Measurements And Main Results:
Among 1,686 patients with coronavirus disease 2019 admitted to an ICU during the study period, all-cause hospital mortality was 29.7%. Mortality differed significantly over time: 28.7% in Surge 1, 21.3% in Lull 1, 25.2% in Surge 2, 30.2% in Lull 2, 34.7% in Surge 3 (p = 0.007). Mortality was significantly associated with 1) preexisting risk factors (older age, race, ethnicity, lower body mass index, higher Elixhauser Comorbidity Index, admission from a nursing home); 2) clinical status at ICU admission (higher Sequential Organ Failure Assessment score, higher d-dimer, higher C-reactive protein); and 3) ICU interventions (receipt of mechanical ventilation, vasopressors, renal replacement therapy, inhaled vasodilators). After adjusting for baseline and clinical variables, there was a significantly increased risk of mortality associated with admission during Lull 2 (relative risk, 1.37 [95% CI = 1.03-1.81]) and Surge 3 (relative risk, 1.35 [95% CI = 1.04-1.77]) as compared to Surge 1.
Conclusions:
Despite increased experience and evidence-based treatments, the risk of death for patients admitted to the ICU with coronavirus disease 2019 was highest during the fall and winter of 2020. Reasons for this increased mortality are not clear.
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