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Association of Intensive Care Unit Patient Load and Demand With Mortality Rates in US Department of Veterans Affairs Hospitals During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is greater coronavirus disease 2019 (COVID-19) intensive care unit (ICU) strain associated with increased COVID-19 mortality?

Findings  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.

Meaning  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.

Abstract

Importance  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.

Objective  To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain.

Design, Setting, and Participants  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.

Exposures  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.

Main Outcomes and Measures  All-cause mortality was recorded through 30 days after discharge from the hospital.

Results  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).

Conclusions and Relevance  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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Article Information

Accepted for Publication: November 28, 2020.

Published: January 19, 2021. doi:10.1001/jamanetworkopen.2020.34266

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bravata DM et al. JAMA Network Open.

Corresponding Author: Dawn M. Bravata, MD, Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, 1481 W 10th St, HSR&D Mail Code 11H, Indianapolis, IN 46202 (Dawn.Bravata2@va.gov).

Author Contributions: Dr Bravata and Mr Perkins had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Bravata, Arling, Zhang, Zillich, Keyhani.

Acquisition, analysis, or interpretation of data: Bravata, Perkins, L. Myers, Arling, Zhang, Zillich, Reese, Dysangco, Agarwal, J. Myers, Austin, Sexson, Leonard, Dev.

Drafting of the manuscript: Bravata, Arling.

Critical revision of the manuscript for important intellectual content: Bravata, Perkins, L. Myers, Zhang, Zillich, Reese, Dysangco, Agarwal, J. Myers, Austin, Sexson, Leonard, Dev, Keyhani.

Statistical analysis: Bravata, Perkins, Arling, Zhang.

Obtained funding: Bravata.

Administrative, technical, or material support: L. Myers, Reese, J. Myers, Austin, Sexson, Keyhani.

Supervision: Bravata, Zhang.

Conflict of Interest Disclosures: Drs Bravata and Perkins reported receiving grants from the Department of Veterans Affairs during the conduct of the study. Dr Agarwal reported receiving personal fees and travel support from Bayer, Relypsa, Reata, Sanofi, Boehringer, and Merck; personal fees from Janssen, DiaMedica, Lexicon, Akebia, Eli Lilly, and Astra Zeneca; and travel support from Akebia outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the US Department of Veterans Affairs Health Services Research and Development Service Precision Monitoring to Transform Care Quality Enhancement Research Initiative (QUE 15-280).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents of this study do not represent the views of the US Department of Veterans Affairs or the US government.

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