key: cord-0699634-gvqi1ejd authors: Sjöström, Björn; Månsson, Emeli; Viklund Kamienny, Josefin; Östberg, Erland title: Characteristics and definitive outcomes of COVID‐19 patients admitted to a secondary hospital intensive care unit in Sweden date: 2021-12-14 journal: Health Sci Rep DOI: 10.1002/hsr2.446 sha: 6b1f954f855275b818b377829cc7e39f022fb52f doc_id: 699634 cord_uid: gvqi1ejd BACKGROUND AND AIMS: Most published reports of COVID‐19 Intensive Care Unit (ICU) patients are from large tertiary hospitals and often present short‐term or incomplete outcome data. There are reports indicating that ICUs with fewer beds are associated with higher mortality. This study aimed to investigate the definitive outcome and patient characteristics of the complete first wave of COVID‐19 patients admitted to ICU in a secondary hospital. METHODS: In this prospective observational study, all patients with respiratory failure and a positive SARS‐CoV‐2 test admitted to Västerås Hospital ICU between 24 March and July 22, 2020 were included. The primary outcome was defined as 90‐day mortality. Secondary outcomes included ICU length of stay, hospital length of stay, number of days with invasive ventilation, need for vasopressors/inotropes, and use of renal replacement therapy. RESULTS: Fifty‐three patients were included. Median age (range) was 59 (33‐76) and 74% were men. Obesity and hypertension were the most common comorbidities and 45% of the patients were born outside Europe. Ninety‐day mortality was 30%. Median ICU length of stay (interquartile range) was 14 (5‐24) days and the duration of invasive mechanical ventilation 16 (12‐26) days. No patients received dialysis at 90‐day follow‐up. CONCLUSION: In this cohort of COVID‐19 patients treated in a secondary hospital ICU, mortality rates were low compared to early studies from China, Italy, and the United States, but similar to other government‐funded hospitals in Scandinavia. A preparatory reorganization enabled an increase in ICU capacity, hence avoiding an overwhelmed intensive care organization. The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has put a serious strain on Intensive Care Units (ICUs) around the globe. Vast regional differences in disease burden have been reported along with variable mortality rates. [1] [2] [3] [4] [5] [6] Sweden has received media attention for its pandemic strategy and demonstrated in late 2020, an eight-times higher mortality rate than the most Västerås Hospital is a public, secondary care hospital situated approximately a one-hour drive from the capital city of Stockholm. As for all ICUs in Sweden, the care provided is entirely government-funded. Patients in need of ECMO, cardiac-, or neurosurgery are referred to tertiary hospitals in Stockholm or Uppsala. During the first wave of the pandemic in early 2020, the viral transmission in the region exhibited an approximate 2-week delay compared to Stockholm. This enabled a substantial reorganization, to prepare for the anticipated surge of patients requiring intensive care. Elective non-malignant surgery was postponed, and overall, elective surgery capacity was reduced to 50% to enable expanded ICU cohort care. One of the post-anesthesia care units in the hospital was rearranged to create a separate enclosed ICU with 14 beds dedicated to COVID-19 patients. The general ICU capacity for non-COVID-19 patients was reduced from eight to five beds. Physicians and nurses without intensive care training from other parts of the health care system were relocated to assist in the new ICU. Anaesthetic ventilators from the operating theatre were brought in and rationing of syringe pumps became necessary. Commonly used sedatives like propofol and remifentanil were intermittently out of stock and substituted for longer-acting agents such as midazolam and morphine. Frequent prioritization of patients eligible for either continuous renal replacement therapy or hemodialysis had to be done according to availability and hemodynamic stability. surviving patients treated in the ICU more than 4 days, and who accepted an invitation to the post-ICU reception. As a further secondary outcome, one-year mortality was also added. Mere descriptive statistics were used due to the size of the study population. Data are described using median (range), median (interquartile range), and count (percentage). In the total cohort, the median age (range) was 59 (33-76) and most patients were men, 39/53 (74%) ( Table 1) . Age distribution is outlined in Figure 3 . The most common comorbidity was obesity, followed by hyper- Distress syndrome (ARDS), according to the Berlin criteria (Table 3) . 18 Neuromuscular blockade and prone positioning were used in 70 and 65%, respectively, of the patients receiving invasive mechanical ventilation (Table 4) . A continuous dialogue with ECMO-centers at tertiary hospitals was held for all patients with refractory hypoxemia but none of these were deemed eligible after assessment. A complete 90-day follow-up of the entire cohort was carried out at the study end point, October 20, 2020. Sixteen patients (30%) had died, of whom 15 in the ICU, most often after a decision to discontinue life-sustaining support ( Table 5 ). The mortality rate for patients receiv- This prospective observational cohort study describes the definitive outcome of the complete first wave of patients treated in the ICU of a secondary hospital with a pre-pandemic low ICU capacity. and widespread treatment with dexamethasone. 16 The results from this study reflect the early phase of the pandemic, since only the last two patients to be admitted received dexamethasone in accordance with The RECOVERY Collaborative Group study. 16 One factor that has been suggested to affect mortality is ICU capacity. 9 The study has important limitations. The sample was small and did not allow statistical analyses to be performed of, for example, factors associated with poor outcome. The small sample size and the regional nature of the data naturally enable limited generalization. The strength of this study is its prospective nature with the inclusion of every available patient and complete 90-day follow-up for the entire cohort. The record of patient characteristics had almost no missing data. To increase our understanding of COVID-19 and difficulties in delivering intensive care during a pandemic, long-term outcomes are needed, and national and regional differences should be considered. Therefore, reports from secondary hospitals constitute a complement to studies from large, tertiary hospitals. Outcomes from intensive care in patients with COVID-19: a systematic review and meta-analysis of observational studies COVID-19 Lombardy ICU network. Risk factors associated with mortality among patients with COVID-19 in intensive care units in Lombardy, Italy COVID-19-associated critical illness-report of the first 300 patients admitted to intensive care units at a New York City medical center Clinical course and outcomes of 344 intensive care patients with COVID-19 Karolinska intensive care COVID-19 study group. 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