ABSTRACT
Objective: To compare the utilization of oxygen therapies and clinical outcomes of patients admitted for COVID-19 during the second surge of the pandemic to that of patients admitted during the first surge. Design(s): Observational study using a registry database. Setting(s): Three hospitals (791 inpatient beds and 76 intensive care unit [ICU] beds) within the Beth Israel Lahey Health system in Massachusetts. Participant(s): We included 3183 patients with COVID-19 admitted to hospitals. Measurements: Baseline data included demographics and comorbidities. Treatments included low-flow supplemental oxygen (2-6 L/min), high-flow oxygen via nasal cannula, and invasive mechanical ventilation. Outcomes included ICU admission, length of stay, ventilator days, and mortality. Result(s): A total of 3183 patients were included: 1586 during the first surge and 1597 during the second surge. Compared to the first surge, patients admitted during the second surge had a similar rate of receiving low-flow supplemental oxygen (65.8% vs 64.1%, P= .3), a higher rate of receiving high-flow nasal cannula (15.4% vs 10.8%, P= .0001), and a lower ventilation rate (5.6% vs 9.7%, P< .0001). The outcomes during the second surge were better than those during the first surge: lower ICU admission rate (8.1% vs 12.7%, P< .0001), shorter length of hospital stay (5 vs 6 days, P< .0001), fewer ventilator days (10 vs 16, P= .01), and lower mortality (8.3% vs 19.2%, P< .0001). Among ventilated patients, those who received high-flow nasal cannula had lower mortality. Conclusion(s): Compared to the first surge of the COVID-19 pandemic, patients admitted during the second surge had similar likelihood of receiving low-flow supplemental oxygen, were more likely to receive high-flow nasal cannula, were less likely to be ventilated, and had better outcomes. Copyright © 2022 Turner White Communications Inc.. All rights reserved.
ABSTRACT
INTRODUCTION: Variation in practice regarding the use of High Flow Nasal Cannula (HFNC) existed among hospitals during the COVID-19 pandemic. We hypothesized that patients who received HFNC prior to requiring mechanical ventilation (MV) would have improved mortality when compared to patients treated with conventional oxygen therapy (COT). METHODS: We conducted a prospective observational study of patients admitted to a tertiary care center between March and May 2020. We included consecutive adult patients with confirmed COVID-19 related ARDS who required MV. We excluded patients treated with NIV. Demographic data were collected and outcomes were censored at day 28. HFNC was initiated at the treating provider's discretion as well as availability of equipment and negative pressure rooms. Patients receiving HFNC therapy received oxygen at 20-60L/min with FiO2 to keep oxygen saturation >92%. COT was delivered with a non-rebreather mask or reservoir nasal cannula at 10-15L/min. Decision to proceed with MV was at clinician discretion. We used Student's t-test, Wilcoxon Rank-Sum, Fisher's Exact, and Chi-Square for statistical analysis. RESULTS: 92 patients were included. 58% were male and the mean age was 68±12 years. Thirty (33%) patients were treated with HFNC prior to MV. Patients in the COT group had more CAD and CHF when compared to patients in the HFNC group (13 vs 1, p=0.03 and 8 vs. 0, p=0.05). HFNC was provided for a median of 21 (IQR 9-36) hours vs. COT for 4 (IQR 1-11) hours prior to MV (p=<.0001) There was no difference in the initial PaO2/FiO2 ratio (152±62 HFNC vs. 153±67 COT, p-0.95). The mean SOFA score was significantly lower in the HFNC group compared to the COT group (6.6 vs. 7.7, p=0.05). The mortality rate was 30% in the HFNC group versus 52% in the COT group (p=0.05), with a trend toward lower mortality with HFNC (OR 0.38, 95% CI 0.12-1.15, p=0.09) after controlling for other predictors of mortality. CONCLUSIONS: Our results indicate a trend toward mortality benefit in COVID-19 patients with ARDS who were treated with HFNC compared with COT prior to intubation.
ABSTRACT
INTRODUCTION: Our hospital experienced a surge in ICU capacity during the COVID-19 pandemic and adopted a tiered provider staffing model. We hypothesized that ICUs staffed with a tiered model would result in similar patient outcomes as ICUs staffed with a traditional intensivist model. METHODS: The study was conducted at a tertiary care center with 52 ICU beds staffed with a 24/7 intensivist coverage model. During the pandemic, ICU capacity was doubled and ICUs with COVID-19 patients were staffed by either an intensivist or by a non-intensivist under the direction of an intensivist using a tiered system. We included adult ICU patients with ARDS and suspected or confirmed COVID-19 between March and May of 2020. We collected demographics, COVID-19 and ARDS treatments, and outcomes of interest in traditionally staffed ICUs vs. ICUs staffed with a tiered model. The primary outcome was inpatient mortality. All outcomes were censored at day 28. We used Student's t-test, Wilcoxon Rank-Sum, Fisher's Exact, and Chi-Square for statistical analysis. RESULTS: A total of 138 patients were included: 66 admitted to traditionally staffed ICUs and 52 to tiered staffing ICUs. The mean age was 67±12.1 years, 63% were male, and the mean SOFA score on admission was 7.5±2.9. Baseline characteristics were similar between groups. More patients in the tiered staffing ICUs received convalescent plasma (14 vs 3%, p=0.05) and azithromycin (41 vs 23%, p=0.05). There was no difference in other COVID-19 treatments, including corticosteroids, tocilizumab, and hydroxychloroquine. ARDS treatments were similar in traditionally staffed ICUs vs tiered staffing model ICUs, including daily median tidal volumes (6.2 vs. 6.2mL/kg, p=0.95), median daily fluid balance (159 vs. 92mL, p=0.54), and use of prone ventilation (58 vs. 65%, p=0.45). There was no difference in inpatient mortality between groups (50 vs. 42%, p=0.46). Successful extubation rates were similar between groups (36 vs. 40%, p=0.71). We also found no difference in ventilator-free, ICU-free, vasopressor-free, and dialysis-free days between groups. CONCLUSIONS: Patient outcomes were similar using a traditional vs. a tiered ICU staffing model during a pandemic. Our analysis is limited by its observational nature and confounded by other healthcare team staffing models.
ABSTRACT
INTRODUCTION: Beth Israel Lahey Health (BILH) formed in March 2019 incorporating 2 legacy systems and 3 independent hospitals. In March 2020, during the surge of COVID-19 in MA, BILH formed a Critical Care Group (CCG) to assist patient load balancing and equipment leveling across all 12 hospitals. METHODS: CCG members included ICU leaders from 3 tertiary hospitals and the BILH Chief Medical Officer. The team huddled twice daily, and developed ICU bed and ventilator surge plans, and pathways for balancing across the network. Requests for transfers from referring hospitals were redirected to BILH hospitals with capacity. CCG made strategic decisions to transfer patients within BILH so that no single hospital became overwhelmed. CCG invited 3 Safety Net Hospitals (SNHs) to the huddles;each SNH was in a COVID ?hotspot,? and the CCG accommodated their transfers. RESULTS: The CCG enabled BILH to flex to 238% of the system's baseline 224 licensed ICU beds. At peak, BILH's tertiary hospital ICUs had an occupancy at 157% of baseline, with 73% of ICU patients on ventilators. From 3/1-6/30, one of the tertiary BILH hospitals accepted 81 SNH ICU transfers;support for SNHs was critical for the overall State response to the surge. Unexpected benefits of the CCG included providing a platform for communication and knowledge sharing;discussions included standardization for tracheostomy procedures, management of ECMO resources, avoidance of pitfalls using anesthesia machines as ventilators, and protocols for proning. As a new system, these strengthened relationships between legacy hospital systems. In addition, MA developed a similar CCG, with the aim of the state's largest hospitals having awareness of how other hospitals' ICUs were managing the surge. CONCLUSIONS: CCG was essential to the BILH system as it facilitated a real-time adaptive response to the surge. Key elements included: 1) Creating a team of senior Critical Care leadership, all of whom were closely in tune with their respective ICU's current status and needs 2) CCG relied on a dashboard that provided daily data on ICU capacity at each hospital, allowing for real-time decision-making 3) Early planning prior to the influx of patients;the CCG formed when the COVID critical care census system-wide was 5, relative to a census of 190 at peak surge.