key: cord-0051874-4p6e2vpv authors: Zhang, Peng; Duggal, Abhijit; Sacha, Gretchen L.; Keller, Joseph; Griffiths, Lori; Khouli, Hassan title: System-wide strategies were associated with improved outcome in critically ill COVID-19 patients – experience from a large Healthcare Network date: 2020-10-21 journal: Chest DOI: 10.1016/j.chest.2020.10.029 sha: ec180f498527fe0b97cbbe7a32aa8211167e2e90 doc_id: 51874 cord_uid: 4p6e2vpv nan To the Editor: The coronavirus disease 2019 (COVID-19) associated critical illness poses an unprecedented challenge to intensive care unit (ICU) capacity and resources [1, 2] with an estimated mortality of 41.6% and long ICU stay [3] . Initial data has linked multiple patient-level risk factors with worse clinical outcomes [4, 5] including older age, pre-existing conditions (diabetes, hypertension, and obesity), initial illness severity, acute inflammation markers and coagulation [4, 5] . However, few studies reported the impact of hospitallevel factors on ICU outcome. Furthermore, no report has compared clinical outcomes between patients with COVID-19 and non-COVID-19 related critical illness during the pandemic's initial phase. We described the temporal trend of outcomes in ICU patients with and without COVID-19 across 9 hospitals within a large regional healthcare system in Northeastern Ohio. Between 3/1/2020 and 6/30/2020, all adult patients admitted to ICU in 9 hospitals across the Cleveland Clinic healthcare system were included. Patients remained hospitalized on 6/30/2020 were excluded from the analysis (< 5%). De-identified individual demographics, Acute Physiology and Chronic Health Evaluation (APACHE) III score [6] on day 1 of ICU admission, laboratory-confirmed COVID-19 status(positive vs negative), and key treatment information were obtained. We evaluated outcomes including ICU and hospital mortality, ICU and hospital length of stay (LOS), and duration of mechanical ventilation (MV). During the study period, several system-wide COVID-19 specific strategies were devised and implemented, including: 1) establishment of cohort COVID-19 ICU in the major health system hubs; 2) continuous monitoring of ICU occupancy, with pre-determined plan of staffing adjustment, patient triage thresholds, and caseload redistribution; 3) webinars on COVID-19 clinical care targeting all ICU providers; 4) protocolized management to ensure standardization of ICU care; 5) multidisciplinary collaboration involving critical care, infectious disease, nephrology, and palliative care. Chi square test was used to compare mortalities between patients with and without COVID-19. A total of 5,460 patients were included in the study, including 582 (10.7%) with COVID-19. Upon review of monthly temporal trends, there was a steady improvement in ICU outcomes in COVID-19 patients with no significant change in APACHE III scores [Table] . Compared to non-COVID-19 patients, ICU and hospital mortalities were significantly higher in COVID-19 patients in March (both p <0.001), but not statistically different in June (both p = 0.16). Similar trends were observed for hospital mortality, ICU LOS, hospital LOS, and MV duration in COVID-19 group [Figure] . There was no significant difference in the number of mechanically ventilated patients, or the use of Prone Position ventilation. Therapeutic interventions including the use of hydroxychroquine, remdesivir, and steroids were variable, and were consistent with the emerging literature. ICU outcomes for non-COVID-19 group remained relatively unchanged across the study period. This is the first large case series, to our knowledge, from a major healthcare system, that showed continuous improvement in clinical outcomes in patients with COVID-19 related critical illness. Additionally, our study showed that in well prepared healthcare system with sufficient ICU capacity and resources, these outcomes become comparable to those of non-COVID related critical illness, and compared favorably to recently published data from the US and worldwide [3, 7] . These intriguing observations suggest the potential benefits to adopting system-wide COVID-19 specific strategies in managing large pandemic surge. A key benefit was the standardization of ICU care and reduction of therapy variability evidenced by modification of clinical treatment practice in response to emerging evidence. Recent studies reported wide variability in adoption and implementation of different therapies for COVID-19 patients across hospitals the US with a subsequent wide range in 28-day in-hospital mortality(6.6%-80.8%) [8] . Conversely, our system-wide strategies maximized the ability to provide optimal and standardized ICU care to all patients and resulted better clinical outcomes. J o u r n a l P r e -p r o o f A healthcare system's early preparation and planning is critical during pandemic outbreak. Facing patient surge, systems must assess capacity and capability early, and begin to implement structures and processes for navigating through the surge. In the US, up to 32% of hospitalized COVID-19 patients can require ICU admission [7] and the caseload is unevenly distributed, even among hospitals within a network. Healthcare systems can preemptively optimize inter-hospital workflow to redistribute patients so no one hospital or ICU has disproportionate disease burden. Before patient surge occurred in Northeastern Ohio, our critical care incident command team and individual hospitals jointly created comprehensive multi-department action plans. These action plans included redeployment of personnel based on needs across ICUs, identification of space for additional ICU capacity, and early dissemination of clinical knowledge on COVID-19 with participation and "buy-in" across stakeholders from the different ICUs. This is the first study to compare outcomes associated with COVID-19 to other ICU admissions in the United States. Using well-validated APACHE III scoring system, we reported a large cohort of ICU patients across 9 hospitals with high critical illness severity. As a result, our study has good generalizability, and our data is an accurate representation of the mortality rate of critically ill COVID-19 patients in a controlled surge situation after care standardization. We acknowledge that this study does not address potential confounders associated with the possible temporal changes in patient demographics and disease characteristics. To mitigate the risk of bias, we compared all the outcomes of interest in non-COVID-19 patients as a general representation of our ICU population. While acknowledging the changes in the utilization of certain therapies including remdesivir and the potential effect on patients' clinical outcomes, we believe the temporal improvement in mortality in our cohort cannot be explained solely by these therapies, especially given the results of recent randomized controlled trials [9, 10] . This study is a snapshot of patients with COVID-19 associated critical illness across a large regional healthcare system in the initial phase of the pandemic. We show that ICU outcomes have significantly improved in COVID-19 patients and were comparable to outcomes in non-COVID ICU related admissions. Furthermore, we believe that development and implementation of system-wide COVID-19 specific strategies can have a significant impact. Facing a pandemic such as COVID-19, healthcare systems should consider similar measures to promote optimal resource allocation and standardization of care. outcomes including duration on MV, LOS, and mortality continued to improve over time; these outcomes for patients without COVID-9 remained largely unchanged. In A-D, the columns represent the medians of data, and the vertical lines represent interquartile range; in E and F, the solid lines represent the actual mortality rate, and the shaded areas represent the 95% confidence interval. J o u r n a l P r e -p r o o f the APACHE III score remained stable in patients with or without COVID-19 infection. B-F: In COVID-19 patients, ICU outcomes including duration on MV, LOS, and mortality continued to improve over time; these outcomes for patients without COVID-9 remained largely unchanged. In A-D, the columns represent the medians of data, and the vertical lines represent interquartile range; in E and F, the solid lines represent the actual mortality rate, and the shaded areas represent the 95% confidence interval. Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US Outcomes from intensive care in patients with COVID-19: a systematic review and meta-analysis of observational studies Predictors of mortality in hospitalized COVID-19 patients: A systematic review and meta-analysis Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study The APACHE III prognostic system: Risk prediction of hospital mortality for critically III hospitalized adults Risk Factors for Intensive Care Unit Admission and In-hospital Mortality among Hospitalized Adults Identified through the U.S. Coronavirus Disease 2019 (COVID-19)-Associated Hospitalization Surveillance Network Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US Dexamethasone in Hospitalized Patients with Covid-19 -Preliminary Report Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial PP = prone position ventilation defined as patients received more than 2 dose of IV or PO prednisone, dexamethasone, hydrocortisone, or methylprednisolone COVID-19: coronavirus disease 2019 ICU: intensive care unit APACHE: Acute Physiology and Chronic Health Evaluation LOS: length of stay MV: mechanical ventilation PP: prone position ventilation Acknowledgement: The authors would like to thank Eric Vogan, MSPH, for his assistance with data extraction from the electronic medical record.