ABSTRACT
RATIONALE: Patients with coronavirus disease 2019 (COVID-19) are frequently admitted to the intensive care unit (ICU) where goals of care conversations may result in changes in code status. Previous work has described how changes in code status in ICU patients influence objective measures like length of stay and mortality and the subjective experiences of patients and surrogates. To date, no study has described the code statuses of ICU patients with COVID-19. METHODS: A retrospective cohort study was performed of all patients admitted to the ICU at three hospitals in Boston, Massachusetts confirmed to have COVID-19 by positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction test between March 11, 2020, and May 31, 2020. Differences in code status at admission were examined. Continuous variables are presented as median and interquartile range (IQR, 1st-3rd) and categorical variables are presented as numbers with percentages. The Mann-Whitney U test was performed for continuous variables and the chi-square test (or Fisher Exact, when appropriate) for categorical variables. RESULTS: A total of 459 patients were admitted to the ICU, of which 421 (91.7%) were Full Code. The median age differed significantly between patients who had a Do Not Resuscitate (DNR) order and those who were Full Code [80.5 (IQR 64-97) versus 62 (IQR 40-84), p < 0.001]. There were no differences in gender or BMI. At admission, sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS II) scores were significantly higher in patients with DNR orders (p = 0.028, p < 0.001 respectively). The median Pao2 / Fio2 ratio at admission was 163 (IQR 43-283) and did not differ between groups. Patients who had DNR orders were more likely to be non-Latinx (86.8% vs 50.4%, p < 0.001), white (81.6% vs 54.2%, p < 0.012), and English-speaking (78.9% vs 48.5%, p < 0.001). Patients admitted from a private home, rather than a facility, were significantly more likely to be Full Code (85.0% vs 36.8%, p < 0.001). CONCLUSIONS: In our cohort, patients with DNR orders at admission were older, white, and non-Latinx, consistent with prior research in general ICU populations. We further identified a significant relationship between primary language and code status. Due to the unique barriers to communication imposed by the COVID-19 pandemic, and pre-existing barriers to communication with patients with limited English proficiency, our results highlight the necessity of specific interventions to overcome these challenges.
ABSTRACT
Rationale: Early in the coronavirus disease 2019 (COVID-19) pandemic there was significant practice variation among hospitals regarding the choice and timing of treatments for acute respiratory failure. It is unknown whether this practice variation contributed to outcome differences. Methods: We performed a retrospective study of all adult patients with respiratory failure due to COVID-19 admitted between March 11 and May 31, 2020 to a medical or surgical ICU at three Massachusetts hospitals. Medical charts were manually reviewed by physicians and abstracted into a standardized REDCap database. Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables were performed using R version 4.0.2. Results: Data from 429 patients were analyzed. Among the three institutions, there were significant differences in race, prevalence of hypertension and diabetes mellitus, duration of COVID-19 symptoms on presentation, and days between admission and intubation. Significant differences were observed in presentation acuity by sequential organ failure assessment (SOFA) score but not simplified acute physiology score (SAPS) or PaO2:FiO2 ratios. Hospital A intubated more patients on the day of admission and utilized more inhaled nitric oxide and less immunosuppression (steroids, anti-IL6 agents). Hospital B treated more patients with remdesivir, other experimental antivirals, and early paralysis (within 48 hours of intubation) but less awake prone positioning. Hospital C utilized more non-invasive positive pressure ventilation (NIPPV) and high flow oxygen in lieu of intubation;it also administered more statins and steroids for acute respiratory distress syndrome (ARDS) and used less early proning within 48 hours of intubation. No difference in hydroxychloroquine use was seen across institutions. There were no statistical differences across hospitals in reintubation, ventilator-free days at 28 days, or in-hospital mortality. Transition to comfort measures was more common at hospital C. There was a trend at hospital A toward lower 30-day (A=25.3%, B=32.1%, C=39.4%;p=0.054) and 90-day (A=28.5%, B=36.1%, C=41.4%;p=0.085) mortality. At hospital A there was significantly longer hospital length-of-stay (A=25.0, B=19.0, C=15.0;p=0.004) and ICU length-of-stay (A=18.0, B=15.0, C=12.0;p=0.001). Conclusions: Early in the COVID-19 pandemic in Massachusetts, there were significant differences in patient characteristics and treatments administered across three institutions. One institution demonstrated a trend toward lower 30-day and 90-day mortality despite later presentation from symptom onset, higher admission acuity, and less utilization of remdesivir or steroids. Practice variation across institutions may explain differences in outcomes, independent of baseline characteristics, and should be studied further as it may inform future management of COVID-19.