Critically Ill Adults With Coronavirus Disease 2019 in New Orleans and Care With an Evidence-Based Protocol

Abstract

Background: Characteristics of critically ill adults with coronavirus disease 2019 (COVID-19) in an academic safety net hospital and the effect of evidence-based practices in these patients are unknown.

Research question: What are the outcomes of critically ill adults with COVID-19 admitted to a network of hospitals in New Orleans, Louisiana, and what is an evidence-based protocol for care associated with improved outcomes?

Study design and methods: In this multi-center, retrospective, observational cohort study of ICUs in four hospitals in New Orleans, Louisiana, we collected data on adults admitted to an ICU and tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 9, 2020 and April 14, 2020. The exposure of interest was admission to an ICU that implemented an evidence-based protocol for COVID-19 care. The primary outcome was ventilator-free days.

Results: The initial 147 patients admitted to any ICU and tested positive for SARS-CoV-2 constituted the cohort for this study. In the entire network, exposure to an evidence-based protocol was associated with more ventilator-free days (25 days; 0-28) compared with non-protocolized ICUs (0 days; 0-23, P = .005), including in adjusted analyses (P = .02). Twenty patients (37%) admitted to protocolized ICUs died compared with 51 (56%; P = .02) in non-protocolized ICUs. Among 82 patients admitted to the academic safety net hospital's ICUs, the median number of ventilator-free days was 22 (interquartile range, 0-27) and mortality rate was 39%.

Interpretation: Care of critically ill COVID-19 patients with an evidence-based protocol is associated with increased time alive and free of invasive mechanical ventilation. In-hospital survival occurred in most critically ill adults with COVID-19 admitted to an academic safety net hospital's ICUs despite a high rate of comorbidities.

Keywords: ARDS; COVID-19; critical care.

Figure 1

Study flow diagram.

Figure 2

Ventilator-free days adjusted for APACHE II score on ICU admission. For every increase in APACHE II score, pilot protocol implementation was always associated with increased ventilator-free days. P-value represents result of a linear regression analysis with the dependent variable as ventilator-free days and the independent variables of pilot protocol implementation (P = .007) and APACHE II score.

Figure 3

Number of ventilator-free days along with incidence of tracheal intubation, mortality, and non-invasive ventilation use to prevent intubation over time. Day of admission to an ICU is displayed on the x-axis. Ventilator-free days are displayed on the right y-axis. Incidence of tracheal intubation, death, and noninvasive positive pressure use to prevent intubation is displayed on the left y-axis. The solid and dashed lines represent Gaussian distribution lines. Over the course of the observation period, rates of intubation based on day of ICU admission rose initially and then decreased in the latter half of the observation period. Rates of NIPPV use were low in patients admitted to the ICU at the outset of the observation and increased in patients admitted over time. Mortality rates were highest in patients admitted to the ICU early in the observation and decreased in patients admitted to the ICU later in the observational period. NIPPV = noninvasive positive-pressure ventilation in pilot protocol group; VFDs = ventilator-free days.