Association of Intensive Care Unit Patient Load and Demand With Mortality Rates in US Department of Veterans Affairs Hospitals During the COVID-19 Pandemic.
Association of Intensive Care Unit Patient Load and Demand With Mortality Rates in US Department of Veterans Affairs Hospitals During the COVID-19 Pandemic.
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DOI：
10.1001/jamanetworkopen.2020.34266
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发表时间：
2021-01-04
影响因子：
13.8
通讯作者：
Keyhani S
中科院分区：
文献类型：
--
作者：
Bravata DM;Perkins AJ;Myers LJ;Arling G;Zhang Y;Zillich AJ;Reese L;Dysangco A;Agarwal R;Myers J;Austin C;Sexson A;Leonard SJ;Dev S;Keyhani S
这项队列研究考察了美国退伍军人事务部（VA）重症监护病房中2019年冠状病毒病（COVID-19）患者的病例量和需求与死亡率的关系。2019冠状病毒病重症监护室（ICU）菌株是否与COVID-19死亡率增加相关？在这项对88家美国退伍军人事务部医院收治的8516名COVID-19患者进行的队列研究中，重症监护能力的紧张与COVID-19死亡率的增加有关。在COVID-19患者中，在COVID-19 ICU需求高峰期间在ICU接受治疗的患者的死亡风险比在低需求期间接受治疗的患者高出近2倍。这些研究结果表明，公共卫生官员和医院管理者应该考虑采取干预措施，减少COVID-19 ICU需求，以提高ICU中COVID-19患者的生存率。尽管医院能力的压力与非流行性环境中死亡率的增加有关，但需要进行研究来检查2019冠状病毒病（COVID-19）重症监护能力与死亡率之间的关系。研究COVID-19死亡率是否与COVID-19重症监护病房（ICU）菌株相关。这项队列研究是在2020年3月至8月期间通过实验室聚合酶链反应或抗原检测确诊的COVID-19退伍军人中进行的，这些退伍军人在任何退伍军人事务部（VA）医院接受护理，ICU中有10名或更多COVID-19患者。随访期至2020年11月。数据分析时间为二零二零年三月至十一月。在COVID-19 ICU负荷增加期间在ICU接受COVID-19治疗，负荷定义为患者住院期间ICU中COVID-19患者的平均人数除以该机构的ICU床位数，或COVID-19 ICU需求增加，需求定义为患者住院期间ICU中COVID-19患者的平均人数除以ICU中COVID-19患者的最大人数。记录出院后30天内的全因死亡率。在88家VA医院收治的8516名COVID-19患者中，8014名（94.1%）为男性，平均（SD）年龄为67.9（14.2）岁。死亡率随时间变化，954例患者中有218例（22.9%）在3月份死亡，1594例患者中有399例（25.0%）4月死亡，920例患者中有143例（15.5%）5月死亡，1314例患者中有179例2373例患者中有297例（12.5%）死于7月，1361例患者中有174例（12.8%）死于8月（P < .001）。与在COVID-19 ICU需求低时期接受治疗的患者相比，在COVID-19 ICU需求增加时期接受治疗的COVID-19患者的死亡风险增加（即，需求≤25%）;全因死亡率的校正风险比为0.99（95% CI，0.81-1.22; P = 0.93）对于COVID-19 ICU需求超过25%至50%时接受治疗的患者，1.19（95%CI，0.95-1.48; P = 0.13），当COVID-19 ICU需求超过50%至75%时为1.94（95%CI，1.46-2.59; P <0.001）。对于未在ICU的COVID-19患者，未观察到COVID-19 ICU需求与死亡率之间的相关性。COVID-19 ICU负荷与死亡率之间的相关性在时间上并不一致（即大流行的早期与晚期）。这项队列研究发现，尽管设施在大流行期间增加了ICU容量，但重症监护能力的压力与COVID-19 ICU死亡率的增加有关。跟踪COVID-19 ICU需求可能对医院管理人员和卫生官员有用，因为他们协调各医院的COVID-19入院，以优化这种疾病患者的结果。
This cohort study examines the association of patient caseload and demand with mortality among patients with coronavirus disease 2019 (COVID-19) in US Veterans Affairs (VA) intensive care units. Is greater coronavirus disease 2019 (COVID-19) intensive care unit (ICU) strain associated with increased COVID-19 mortality? In this cohort study of 8516 patients with COVID-19 admitted to 88 US Veterans Affairs hospitals, strains on critical care capacity were associated with increased COVID-19 mortality. Among patients with COVID-19, those treated in the ICU during periods of peak COVID-19 ICU demand had a nearly 2-fold increased risk of mortality compared with those treated during periods of low demand. These findings suggest that public health officials and hospital administrators should consider interventions that reduce COVID-19 ICU demand to improve survival among patients with COVID-19 in the ICU. Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient’s hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient’s stay divided by the maximum number of patients with COVID-19 in the ICU. All-cause mortality was recorded through 30 days after discharge from the hospital. Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P < .001). Patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID-19 ICU demand (ie, demand of ≤25%); the adjusted hazard ratio for all-cause mortality was 0.99 (95% CI, 0.81-1.22; P = .93) for patients treated when COVID-19 ICU demand was more than 25% to 50%, 1.19 (95% CI, 0.95-1.48; P = .13) when COVID-19 ICU demand was more than 50% to 75%, and 1.94 (95% CI, 1.46-2.59; P < .001) when COVID-19 ICU demand was more than 75% to 100%. No association between COVID-19 ICU demand and mortality was observed for patients with COVID-19 not in the ICU. The association between COVID-19 ICU load and mortality was not consistent over time (ie, early vs late in the pandemic). This cohort study found that although facilities augmented ICU capacity during the pandemic, strains on critical care capacity were associated with increased COVID-19 ICU mortality. Tracking COVID-19 ICU demand may be useful to hospital administrators and health officials as they coordinate COVID-19 admissions across hospitals to optimize outcomes for patients with this illness.
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DOI：
10.1056/nejmoa2022926
发表时间：
2020-11-19
期刊：
The New England journal of medicine
影响因子：
--
作者：
RECOVERY Collaborative Group;Horby P;Mafham M;Linsell L;Bell JL;Staplin N;Emberson JR;Wiselka M;Ustianowski A;Elmahi E;Prudon B;Whitehouse T;Felton T;Williams J;Faccenda J;Underwood J;Baillie JK;Chappell LC;Faust SN;Jaki T;Jeffery K;Lim WS;Montgomery A;Rowan K;Tarning J;Watson JA;White NJ;Juszczak E;Haynes R;Landray MJ
通讯作者：
Landray MJ
影响因子：
3.3
作者：
Sohn MW;Arnold N;Maynard C;Hynes DM
通讯作者：
Hynes DM
影响因子：
9.6
作者：
Einav, Sharon;Hick, John L.;Christian, Michael D.
通讯作者：
Christian, Michael D.
影响因子：
1.8
作者：
Kim, Je Hyeong;Hong, Suk-Kyung;Hong, Sung Jin
通讯作者：
Hong, Sung Jin
影响因子：
120.7
作者：
Pan, An;Liu, Li;Wu, Tangchun
通讯作者：
Wu, Tangchun