RESUMEN
Background Hospital adaptation and resiliency, required during public health emergencies to optimize outcomes, are understudied especially in resource-limited settings. Research Question Measure pre-pandemic and pandemic critical illness outcomes in a resource-limited setting and in the context of capacity strain. Study Design and Methods We performed a retrospective cohort study among patients admitted to ICUs at two public hospitals in the KwaZulu-Natal Department of Health in South Africa preceding and during the COVID-19 pandemic (2017-2022). We used multivariable logistic regression to analyze the association between three patient cohorts (pre-pandemic non-COVID-19, pandemic non-COVID-19, and pandemic COVID-19) and ICU capacity strain and the primary outcome of ICU mortality. Results 3,221 patients were admitted to the ICU during the pre-pandemic period and 2,539 patients were admitted to the ICU during the pandemic period (375 [14.8%] with COVID-19 and 2,164 [85.2%] without COVID-19). The pre-pandemic and pandemic non-COVID-19 cohorts were similar. Compared to the non-COVID-19 cohorts, the pandemic COVID-19 cohort had older age, higher rates of chronic cardiovascular disease and diabetes, less extra-pulmonary organ dysfunction, and longer ICU length of stay. Compared to the pre-pandemic non-COVID-19 cohort, the pandemic non-COVID-19 cohort had similar odds of ICU mortality (OR 1.06, 95% CI 0.90-1.25, p = 0.50) while the pandemic COVID-19 cohort had significantly increased odds of ICU mortality (OR 3.91, 95% CI 3.03-5.05 p < 0.0005). ICU occupancy was not associated with ICU mortality in either the COVID-19 cohort (OR 1.05 per 10% change in ICU occupancy, 95% CI 0.96-1.14, p = 0.27) or the pooled non-COVID-19 cohort (OR 1.01 per 10% change in ICU occupancy, 95% CI 0.98-1.03, p = 0.52). Interpretation Pre-pandemic and pandemic non-COVID-19 ICU patients were broadly similar in clinical characteristics and outcomes, suggesting critical care resiliency, while pandemic COVID-19 ICU patients had important clinical differences and had significantly higher mortality.