key: cord-0908210-yusxsir4
authors: Perez Gutierrez, V. A.; Carlos, A.; Osella, J.; Nino, J.; Kasubhai, M.; Dimitrov, V.; Menon, V.
title: Comparison of clinical course and outcomes of critically ill patients with SARS-CoV2 infection managed in traditional ICU and "Flex" ICU during the surge of the pandemic in the Bronx.
date: 2021-03-07
journal: nan
DOI: 10.1101/2021.03.03.21252868
sha: c98e8a6e21c052c899d28df92b2b6e8a291d9448
doc_id: 908210
cord_uid: yusxsir4

BACKGROUND: As part of the response to increasing critical care capacity during the unprecedented surge of COVID-19 infections, NYC Health + Hospital systems identified and resourced areas in the hospital that could deliver critical care as "Flex" ICUs to complement the traditional ICUs to manage the rapid influx of critically ill patients. OBJECTIVE: Comparison of clinical features and outcomes of mechanically ventilated COVID-19 patients admitted to the traditional and "Flex" ICUs during the surge of the pandemic. METHODS: Retrospective comparative cohort study of patients with confirmed SARS-CoV-2 infection on mechanical ventilation admitted to traditional ICU and 'Flex' ICU. Univariate and multivariate analyses were conducted to detect factors associated with death from COVID-19 patients in mechanical ventilation by the Cox proportional hazards regression model. RESULTS: Out of the 312 patients on mechanical ventilation, 111(35.6%) were admitted to the traditional ICU, and 201(64.4%) to the 'Flex' ICU. The mortality rate was higher in the 'Flex' ICU compared with the traditional ICU (H.R., 1.37, 95% CI, 1.05-1.81, p<0.05), but the adjusted risk model was not significantly associated with increased mortality (adjusted, H.R., 1.29, 95% CI, 0.97-1.71, p=0.078). CONCLUSION "Flex" ICUs played a crucial role in critically ill patients' management during the pandemic. The mortality risk of patients in the "Flex" ICU was comparable to traditional ICUs in the adjusted analysis. While there is enough evidence for Intensivist managed ICUs to have better outcomes, our study demonstrates the feasibility of non-intensivist leading "Flex" ICUs during a crisis.

An already strained US critical care system was overwhelmed during the peak of the pandemic, as anticipated by experts based on experience from China and Italy (1) . Initial reports from China suggested that approximately 5% of proven COVID-19 infections required intensive care (2) ; however, in the United States, as per the CDC report in March 2020, the hospitalization rate was 20.7-31.4% with 4.9-11.5% requiring intensive care (3, 4) . As New York City became the epicenter of the operational needs across the eleven-hospital system were recognized, and efforts to increase capacity and resources were implemented.

Critical care capacity was expanded system wide, with an increase from 300 bed ICU capacity at baseline to over 1000 beds. This was possible by increasing formal critical care beds, use of nontraditional All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 7, 2021. ;  https://doi.org/10.1101/2021.03.03.21252868 doi: medRxiv preprint hospital space creatively, increase adequate staffing, and supplement the supply of necessary equipment (5) . Additional areas in the hospital that potentially had the logistics to deliver critical care were identified as "flex" ICU spaces. Optimum utilization of the available space was done by using oxygen "splitters," retrofitting rooms with windows using High-Efficiency Particulate Air (HEPA) filters vented externally to create negative pressure rooms to increase capacity while following infection control requirements (5) . The increase in number of patients with severe/critical COVID also placed a significant strain on staffing, especially ICU staffing across H+H. In addition to the redeployment of staff from suspended services like ambulatory care, a tiered staffing structure using intensivists and ICU nurses guided the non-ICU trained providers and increased ability to provide high-quality critical care. The system partnered with the US Department of Defense and engaged volunteers and private staffing agencies to help meet the demand of qualified personnel (6) .

While traditional ICUs managed by intensivists have been well known to deliver better outcomes, we examined the comparison of clinical features and outcomes of severe/critical COVID-19 patients requiring intensive care admitted to the traditional and "Flex" ICUs during the surge of the pandemic.

This single center, retrospective, observational study was done at the NYC H+H in the Bronx. Patients with confirmed COVID-19 infection All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Patients admitted in the ICU and FLEX were comparable concerning baseline characteristics (table 1) .

While the incidence of Acute respiratory distress syndrome on admission was 59% among patients admitted to traditional ICU, it was 65% among those in the Flex ICU cohort. The stratification of the ARDS between traditional and Flex ICU was Mild ARDS (13% vs. 14%), moderate ARDS (33% vs. 37%), and severe ARDS (43% vs. 41%) ( Table 1 ). The Apache II score within 24 hours on intubation was comparable between the two groups (median, 13 vs. 14). The majority of patients in both All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

It is well established that critically ill patients have decreased mortality and length of stay when managed by trained intensivists (14) (15) (16) . Due to the unprecedented demand for critical care services at the peak of the pandemic, hospitalists and surgeons stepped up to provide intensive care in the designated "Flex" ICUs. Our study presents the comparison of patient outcomes between a traditional ICU and Flex ICU. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 7, 2021. Going forward with lessons learned from this experience, it is valuable to build capacity with respect to critical care staffing, cross-training physicians, nurses, and allied health specialists for intensive care, and map out a workflow to increase beds including ICU beds and source supplies to respond to the next wave of infections. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 7, 2021. All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 11.02 ( (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 7, 2021. ; https://doi.org/10.1101/2021.03.03.21252868 doi: medRxiv preprint

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