Dawn M Bravata1,2,3,4,5,6, Anthony J Perkins1,7, Laura J Myers1,2,4,6, Greg Arling1,8, Ying Zhang1,9, Alan J Zillich10, Lindsey Reese3,4, Andrew Dysangco3,4, Rajiv Agarwal3,4, Jennifer Myers1,2, Charles Austin1,2, Ali Sexson1,2, Samuel J Leonard11, Sharmistha Dev2,3,6, Salomeh Keyhani1,12,13. 1. Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, Indiana. 2. Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana. 3. Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana. 4. Department of Medicine, Indiana University School of Medicine, Indianapolis. 5. Department of Neurology, Indiana University School of Medicine, Indianapolis. 6. William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana. 7. Department of Biostatistics, Indiana University School of Medicine, Indianapolis. 8. School of Nursing, Purdue University, West Lafayette, Indiana. 9. Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha. 10. Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana. 11. Northern California Institute for Research and Education, San Francisco. 12. San Francisco VA Medical Center, San Francisco, California. 13. Division of General Internal Medicine, Department of Medicine, University of California, San Francisco.
Abstract
Importance: Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. Objective: To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. Design, Setting, and Participants: This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. Exposures: Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient's hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient's stay divided by the maximum number of patients with COVID-19 in the ICU. Main Outcomes and Measures: All-cause mortality was recorded through 30 days after discharge from the hospital. Results: Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P < .001). Patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID-19 ICU demand (ie, demand of ≤25%); the adjusted hazard ratio for all-cause mortality was 0.99 (95% CI, 0.81-1.22; P = .93) for patients treated when COVID-19 ICU demand was more than 25% to 50%, 1.19 (95% CI, 0.95-1.48; P = .13) when COVID-19 ICU demand was more than 50% to 75%, and 1.94 (95% CI, 1.46-2.59; P < .001) when COVID-19 ICU demand was more than 75% to 100%. No association between COVID-19 ICU demand and mortality was observed for patients with COVID-19 not in the ICU. The association between COVID-19 ICU load and mortality was not consistent over time (ie, early vs late in the pandemic). Conclusions and Relevance: This cohort study found that although facilities augmented ICU capacity during the pandemic, strains on critical care capacity were associated with increased COVID-19 ICU mortality. Tracking COVID-19 ICU demand may be useful to hospital administrators and health officials as they coordinate COVID-19 admissions across hospitals to optimize outcomes for patients with this illness.
Importance: Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. Objective: To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. Design, Setting, and Participants: This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. Exposures: Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient's hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient's stay divided by the maximum number of patients with COVID-19 in the ICU. Main Outcomes and Measures: All-cause mortality was recorded through 30 days after discharge from the hospital. Results: Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P < .001). Patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID-19 ICU demand (ie, demand of ≤25%); the adjusted hazard ratio for all-cause mortality was 0.99 (95% CI, 0.81-1.22; P = .93) for patients treated when COVID-19 ICU demand was more than 25% to 50%, 1.19 (95% CI, 0.95-1.48; P = .13) when COVID-19 ICU demand was more than 50% to 75%, and 1.94 (95% CI, 1.46-2.59; P < .001) when COVID-19 ICU demand was more than 75% to 100%. No association between COVID-19 ICU demand and mortality was observed for patients with COVID-19 not in the ICU. The association between COVID-19 ICU load and mortality was not consistent over time (ie, early vs late in the pandemic). Conclusions and Relevance: This cohort study found that although facilities augmented ICU capacity during the pandemic, strains on critical care capacity were associated with increased COVID-19 ICU mortality. Tracking COVID-19 ICU demand may be useful to hospital administrators and health officials as they coordinate COVID-19 admissions across hospitals to optimize outcomes for patients with this illness.
Authors: Nicole B Gabler; Sarah J Ratcliffe; Jason Wagner; David A Asch; Gordon D Rubenfeld; Derek C Angus; Scott D Halpern Journal: Am J Respir Crit Care Med Date: 2013-10-01 Impact factor: 21.405
Authors: Sharon Einav; John L Hick; Dan Hanfling; Brian L Erstad; Eric S Toner; Richard D Branson; Robert K Kanter; Niranjan Kissoon; Jeffrey R Dichter; Asha V Devereaux; Michael D Christian Journal: Chest Date: 2014-10 Impact factor: 9.410
Authors: Carl O Eriksson; Ryan C Stoner; Karen B Eden; Craig D Newgard; Jeanne-Marie Guise Journal: J Gen Intern Med Date: 2016-12-15 Impact factor: 5.128
Authors: George L Anesi; Vincent X Liu; Nicole B Gabler; M Kit Delgado; Rachel Kohn; Gary E Weissman; Brian Bayes; Gabriel J Escobar; Scott D Halpern Journal: Ann Am Thorac Soc Date: 2018-11
Authors: Je Hyeong Kim; Suk-Kyung Hong; Younghwan Kim; Ho Geol Ryu; Chi-Min Park; Young Seok Lee; Sung Jin Hong Journal: Acute Crit Care Date: 2020-05-31
Authors: Jonathan Duvall; Garrett G Grindle; John Kaplan; David Marks; Lee Sylvers; Jenish Patel; Michael Lain; Andrea Bagay; C S Chung; Rory A Cooper Journal: Technol Innov Date: 2021-12-15
Authors: Ryan C Maves; Stephanie A Richard; David A Lindholm; Nusrat Epsi; Derek T Larson; Christian Conlon; Kyle Everson; Steffen Lis; Paul W Blair; Sharon Chi; Anuradha Ganesan; Simon Pollett; Timothy H Burgess; Brian K Agan; Rhonda E Colombo; Christopher J Colombo Journal: Open Forum Infect Dis Date: 2021-08-10 Impact factor: 3.835
Authors: Jihad Georges Youssef; Philip Lavin; David A Schoenfeld; Richard A Lee; Rainer Lenhardt; David J Park; Javier Perez Fernandez; Melvin L Morganroth; Jonathan C Javitt; Dushyantha Jayaweera Journal: Crit Care Med Date: 2022-08-29 Impact factor: 9.296
Authors: Andrew H Stephen; Sarah B Andrea; Debasree Banerjee; Mohammed Arafeh; Morgan Askew; Stephanie N Lueckel; Tareq Kheirbek; Leonard A Mermel; Charles A Adams; Mitchell M Levy; Daithi S Heffernan Journal: SSM Popul Health Date: 2022-06-15
Authors: Valdery Moura Junior; M Brandon Westover; Feng Li; Eyal Kimchi; Maura Kennedy; Nicole M Benson; Lidia Maria Moura; John Hsu Journal: Health Serv Manage Res Date: 2021-07-11
Authors: Austin J Parish; Jason R West; Nicholas D Caputo; Trevor M Janus; Denley Yuan; John Zhang; Daniel J Singer Journal: Crit Care Explor Date: 2021-06-15
Authors: Bernard Lambermont; Anne-Françoise Rousseau; Laurence Seidel; Marie Thys; Jonathan Cavalleri; Pierre Delanaye; J Geoffrey Chase; Pierre Gillet; Benoit Misset Journal: Crit Care Explor Date: 2021-05-19