Prediction of intensive care admission and hospital mortality in COVID-19 patients using demographics and baseline laboratory data

Introduction Optimized allocation of medical resources to patients with COVID-19 has been a critical concern since the onset of the pandemic. Methods In this retrospective cohort study, the authors used data from a Brazilian tertiary university hospital to explore predictors of Intensive Care Unit (ICU) admission and hospital mortality in patients admitted for COVID-19. Our primary aim was to create and validate prediction scores for use in hospitals and emergency departments to aid clinical decisions and resource allocation. Results The study cohort included 3,022 participants, of whom 2,485 were admitted to the ICU;1968 survived, and 1054 died in the hospital. From the complete cohort, 1,496 patients were randomly assigned to the derivation sample and 1,526 to the validation sample. The final scores included age, comorbidities, and baseline laboratory data. The areas under the receiver operating characteristic curves were very similar for the derivation and validation samples. Scores for ICU admission had a 75% accuracy in the validation sample, whereas scores for death had a 77% accuracy in the validation sample. The authors found that including baseline flu-like symptoms in the scores added no significant benefit to their accuracy. Furthermore, our scores were more accurate than the previously published NEWS-2 and 4C Mortality Scores. Discussion and conclusions The authors developed and validated prognostic scores that use readily available clinical and laboratory information to predict ICU admission and mortality in COVID-19. These scores can become valuable tools to support clinical decisions and improve the allocation of limited health resources.

Prediction of intensive care admission and hospital mortality in COVID-19 patients using demographics and baseline laboratory data.

INTRODUCTION: Optimized allocation of medical resources to patients with COVID-19 has been a critical concern since the onset of the pandemic. METHODS: In this retrospective cohort study, the authors used data from a Brazilian tertiary university hospital to explore predictors of Intensive Care Unit (ICU) admission and hospital mortality in patients admitted for COVID-19. Our primary aim was to create and validate prediction scores for use in hospitals and emergency departments to aid clinical decisions and resource allocation. RESULTS: The study cohort included 3,022 participants, of whom 2,485 were admitted to the ICU; 1968 survived, and 1054 died in the hospital. From the complete cohort, 1,496 patients were randomly assigned to the derivation sample and 1,526 to the validation sample. The final scores included age, comorbidities, and baseline laboratory data. The areas under the receiver operating characteristic curves were very similar for the derivation and validation samples. Scores for ICU admission had a 75% accuracy in the validation sample, whereas scores for death had a 77% accuracy in the validation sample. The authors found that including baseline flu-like symptoms in the scores added no significant benefit to their accuracy. Furthermore, our scores were more accurate than the previously published NEWS-2 and 4C Mortality Scores. DISCUSSION AND CONCLUSIONS: The authors developed and validated prognostic scores that use readily available clinical and laboratory information to predict ICU admission and mortality in COVID-19. These scores can become valuable tools to support clinical decisions and improve the allocation of limited health resources.

Twelve Months and Counting: Following Clinical Outcomes in Critical COVID-19 Survivors.

RATIONALE: Recent reports suggest patients with severe coronavirus disease 2019 (COVID-19) often experience long-term consequences of the infection. However, studies on intensive care unit (ICU) survivors are underrepresented. OBJECTIVES: We aimed to explore 12-month clinical outcomes after critical COVID-19, describing the longitudinal progress of disabilities, frailty status, the frequency of cognitive impairment, and clinical events (rehospitalization, institutionalization, and falls). METHODS: We performed a prospective cohort study of survivors of COVID-19 ICU admissions at Sao Paulo, Brazil. We assessed patients every three months for one year after hospital discharge and obtained information on 15 activities of daily living (basic, instrumental, and mobility activities), frailty, cognition, and clinical events. RESULTS: We included 428 patients (mean age of 64 years, 61% required invasive mechanical ventilation during ICU stay). The number of disabilities peaked at 3 months compared with the pre-COVID-19 period (mean difference 2.46, 99% confidence interval [99%CI] 1.94-2.99) and then decreased at 12 months (mean difference 0.67, 99%CI 0.28-1.07). At 12-month follow-up, 12% of patients were frail, but half of them presented frailty only after COVID-19. The prevalence of cognitive symptoms was 17% at 3 months and progressively decreased to 12.1% (p=0.012 for trend) at the end of one year. Clinical events occurred in all assessments. CONCLUSIONS: Although a higher burden of disabilities and cognitive symptoms occurred three months after hospital discharge of critical COVID-19 survivors, a significant improvement occurred during the one-year follow-up. However, one third of the patients still remained in worse conditions than their pre-COVID status.

Palliative care in hospitalized middle-aged and older adults with COVID-19

Background : As COVID-19 overwhelms health systems worldwide, palliative care strategies may ensure rational use of resources while safeguarding patient comfort and dignity. Aim : To describe palliative care practices in hospitalized middle-aged and older adults in two of the largest COVID-19 treatment centers in Sao Paulo, Brazil. Design : Retrospective cohort Setting/participants : Eligible patients were those aged 50 years or older hospitalized between March and May 2020 with a laboratory confirmation of SARS-CoV-2 infection. Palliative care implementation was defined as present if medical notes indicated a decision to limit escalation of life support measures, or when opioids or sedatives were prescribed for palliative management of symptoms. Results : We included 1162 participants (57% male, median 65 years). Overall, 21% were frail and 54% were treated in intensive care units, but only 17% received palliative care. Stepwise logistic regression demonstrated that age ≥80 years, dementia, history of stroke or cancer, frailty, having a PaO2/FiO2<200 or a C-reactive protein ≥150mg/dl at admission predicted palliative care implementation. Patients placed under palliative care stayed longer (13 vs.11 days) and were more likely to die in hospital (86 vs.27%). They also spent more days in ICU and received vasoactive drugs, hemodialysis, and invasive ventilation more frequently. Conclusions : one in five middle-aged and older adults hospitalized with COVID-19 received palliative care in our cohort. Patients who were very old, multimorbid, frail, and had severe COVID-19 were more likely to receive palliative care. However, it was often delayed until advanced and invasive life support measures had already been implemented.

Delirium and Adverse Outcomes in Hospitalized Patients with COVID-19.

BACKGROUND: Little is known about the association between acute mental changes and adverse outcomes in hospitalized adults with COVID-19. OBJECTIVES: To investigate the occurrence of delirium in hospitalized patients with COVID-19 and explore its association with adverse outcomes. DESIGN: Longitudinal observational study. SETTING: Tertiary university hospital dedicated to the care of severe cases of COVID-19 in São Paulo, Brazil. PARTICIPANTS: A total of 707 patients, aged 50 years or older, consecutively admitted to the hospital between March and May 2020. MEASUREMENTS: We completed detailed reviews of electronic medical records to collect our data. We identified delirium occurrence using the Chart-Based Delirium Identification Instrument (CHART-DEL). Trained physicians with a background in geriatric medicine completed all CHART-DEL assessments. We complemented our baseline clinical information using telephone interviews with participants or their proxy. Our outcomes of interest were in-hospital death, length of stay, admission to intensive care, and ventilator utilization. We adjusted all multivariable analyses for age, sex, clinical history, vital signs, and relevant laboratory biomarkers (lymphocyte count, C-reactive protein, glomerular filtration rate, D-dimer, and albumin). RESULTS: Overall, we identified delirium in 234 participants (33%). On admission, 86 (12%) were delirious. We observed 273 deaths (39%) in our sample, and in-hospital mortality reached 55% in patients who experienced delirium. Delirium was associated with in-hospital death, with an adjusted odds ratio of 1.75 (95% confidence interval = 1.15-2.66); the association held both in middle-aged and older adults. Delirium was also associated with increased length of stay, admission to intensive care, and ventilator utilization. CONCLUSION: Delirium was independently associated with in-hospital death in adults aged 50 years and older with COVID-19. Despite the difficulties for patient care during the pandemic, clinicians should routinely monitor delirium when assessing severity and prognosis of COVID-19 patients.