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Abstract

Objective

To determine whether surge conditions were associated with increased mortality.

Design

Multicenter cohort study.

Setting

U.S. ICUs participating in STOP-COVID.

Patients

Consecutive adults with COVID-19 admitted to participating ICUs between March 4 and July 1, 2020.

Interventions

None

Measurements and Main Results

The main outcome was 28-day in-hospital mortality. To assess the association between admission to an ICU during a surge period and mortality, we used two different strategies: (1) an inverse probability weighted difference-in-differences model limited to appropriately matched surge and non-surge patients and (2) a meta-regression of 50 multivariable difference-in-differences models (each based on sets of randomly matched surge- and non-surge hospitals). In the first analysis, we considered a single surge period for the cohort (March 23 – May 6). In the second, each surge hospital had its own surge period (which was compared to the same time periods in matched non-surge hospitals).

Our cohort consisted of 4342 ICU patients (average age 60.8 [sd 14.8], 63.5% men) in 53 U.S. hospitals. Of these, 13 hospitals encountered surge conditions. In analysis 1, the increase in mortality seen during surge was not statistically significant (odds ratio [95% CI]: 1.30 [0.47-3.58], p = .6). In analysis 2, surge was associated with an increased odds of death (odds ratio 1.39 [95% CI, 1.34-1.43], p < .001).

Conclusions

Admission to an ICU with COVID-19 in a hospital that is experiencing surge conditions may be associated with an increased odds of death. Given the high incidence of COVID-19, such increases would translate into substantial excess mortality.

Keywords

COVID-19 intensive care unit mortality surge occupancy

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References

World Health Organization. Novel Coronavirus (2019-nCoV) Situation Report 1; 2021.

Belluck

Weiland

. C.D.C. Officials Warn of Coronavirus Outbreaks in the U.S. The New York Times; 2020.

Coronavirus now spreading faster outside China. BBC News; 2020.

Kobokovich

. Ventilator stockpiling and availability in the US: Johns Hopkins Center for Health Security; 2020.

Ranney

Griffeth

Jha

. Critical supply shortages - The need for ventilators and personal protective equipment during the covid-19 pandemic. N Engl J Med. Apr 2020;382(18):e41.

Widdicombe

. The coronavirus pandemic peaks in New York's Hospitals. The New Yorker. April 15 2020.

Keene

Shiloh

Eisen

, et al. Critical care surge during the COVID-19 pandemic: implementation and feedback from frontline providers. J Intensive Care Med. Feb 2021;36(2):233‐240.

Gershengorn

. ICU capacity is more about the clinicians than the number of beds. statnews.com; 2020.

Chen

Cai

, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 07 2020;180(7):934‐943.

10.

Richardson

Hirsch

Narasimhan

, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York city area. JAMA. 2020;323(20):2052–2059.

11.

Arentz

Yim

Klaff

, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state. JAMA. 04 2020;323(16):1612‐1614.

12.

Barrot

Asfar

Mauny

, et al. Liberal or conservative oxygen therapy for acute respiratory distress syndrome. N Engl J Med. 03 2020;382(11):999‐1008.

13.

Beitler

Sarge

Banner-Goodspeed

, et al. Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy versus an empirical high PEEP-Fio2 strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 03 2019;321(9):846‐857.

14.

Moss

Huang

Brower

, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 05 2019;380(21):1997‐2008.

15.

Fowler

Truwit

Hite

, et al. Effect of vitamin C infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the CITRIS-ALI randomized clinical trial. JAMA. 10 2019;322(13):1261‐1270.

16.

Wendel Garcia

Fumeaux

Guerci

, et al. Prognostic factors associated with mortality risk and disease progression in 639 critically ill patients with COVID-19 in Europe: initial report of the international RISC-19-ICU prospective observational cohort. EClinicalMedicine. Aug 2020;25:100449.

17.

Auld

Caridi-Scheible

Blum

, et al. ICU and ventilator mortality among critically ill adults with coronavirus disease 2019. Crit Care Med. 09 2020;48(9):e799‐e804.

18.

Bravata

Perkins

Myers

, et al. Association of intensive care unit patient load and demand with mortality rates in US department of veterans affairs hospitals during the COVID-19 pandemic. JAMA Netw Open. 01 2021;4(1):e2034266.

19.

Gupta

Hayek

Wang

, et al. Factors associated with death in critically ill patients with coronavirus disease 2019 in the US. JAMA Intern Med. 2020;180(11):1436–1447.

20.

Vincent

Moreno

Takala

, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European society of intensive care medicine. Intensive Care Med. Jul 1996;22(7):707‐710.

21.

American Hospital Association Regions. American Hospital Association. Accessed February 1, 2021. Available at: https://www.ahvrp.org/sites/default/files/aha-regional-map.pdf

22.

Stuart

Huskamp

Duckworth

, et al. Using propensity scores in difference-in-differences models to estimate the effects of a policy change. Health Serv Outcomes Res Methodol. Dec 2014;14(4):166‐182.

23.

Tanner-Smith

Tipton

. Robust variance estimation with dependent effect sizes: practical considerations including a software tutorial in stata and spss. Res Synth Methods. Mar 2014;5(1):13‐30.

24.

Aiken

Clarke

Sloane

Sochalski

Silber

. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 Oct 23-30 2002;288(16):1987‐1993.

25.

Dang

Johantgen

Pronovost

Jenckes

Bass

. Postoperative complications: does intensive care unit staff nursing make a difference? Heart Lung. 2002 May-Jun 2002;31(3):219‐228.

26.

McGahan

Kucharski

Coyer

. Elsevier WABNRPsb. Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review. Aust Crit Care. May 2012;25(2):64‐77.

27.

Penoyer

. Nurse staffing and patient outcomes in critical care: a concise review. Crit Care Med. Jul 2010;38(7):1521‐1528. quiz 1529.

28.

Gershengorn

Harrison

Garland

Wilcox

Rowan

Wunsch

. Association of intensive care unit patient-to-intensivist ratios with hospital mortality. JAMA Intern Med. Mar 2017;177(3):388‐396.

29.

Dara

Afessa

. Intensivist-to-bed ratio: association with outcomes in the medical ICU. Chest. Aug 2005;128(2):567‐572.

30.

Wilcox

Chong

Niven

, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. Oct 2013;41(10):2253‐2274.

31.

Kashiouris

Sessler

Qayyum

, et al. Near-simultaneous intensive care unit (ICU) admissions and all-cause mortality: a cohort study. Intensive Care Med. 11 2019;45(11):1559‐1569.

32.

Neuraz

Guérin

Payet

, et al. Patient mortality is associated with staff resources and workload in the ICU: a multicenter observational study. Crit Care Med. Aug 2015;43(8):1587‐1594.

33.

Gabler

Ratcliffe

Wagner

, et al. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med. Oct 2013;188(7):800‐806.

34.

Bhonagiri

Pilcher

Bailey

. Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis. Med J Aust. Mar 2011;194(6):287‐292.

35.

Groenland

CNL

Termorshuizen

Rietdijk

WJR

, et al. Emergency department to ICU time is associated with hospital mortality: a registry analysis of 14,788 patients from six university hospitals in the Netherlands. Crit Care Med. 11 2019;47(11):1564‐1571.

36.

Zhang

Bokhari

Guo

Goyal

. Prolonged length of stay in the emergency department and increased risk of hospital mortality in patients with sepsis requiring ICU admission. Emerg Med J. Feb 2019;36(2):82‐87.

37.

Butler

Wong

SPY

Wightman

O’Hare

. US clinicians’ experiences and perspectives on resource limitation and patient care during the COVID-19 pandemic. JAMA Netw Open. 11 2020;3(11):e2027315.

38.

Kadri

Sun

Lawandi

, et al. Association between caseload surge and COVID-19 survival in 558 U.S. hospitals, March to August 2020. Ann Intern Med. Jul 06 2021.174(9):1240–1251.

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Association of Surge Conditions with Mortality Among Critically Ill Patients with COVID-19