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. 2021 Jan 4;4(1):e2034266.
doi: 10.1001/jamanetworkopen.2020.34266.

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

Dawn M Bravata  1   2   3   4   5   6 , Anthony J Perkins  1   7 , Laura J Myers  1   2   4   6 , Greg Arling  1   8 , Ying Zhang  1   9 , Alan J Zillich  10 , Lindsey Reese  3   4 , Andrew Dysangco  3   4 , Rajiv Agarwal  3   4 , Jennifer Myers  1   2 , Charles Austin  1   2 , Ali Sexson  1   2 , Samuel J Leonard  11 , Sharmistha Dev  2   3   6 , Salomeh Keyhani  1   12   13
Affiliations

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

Dawn M Bravata et al. JAMA Netw Open. .

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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Conflict of interest statement

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.

Figures

Figure 1.
Figure 1.. Coronavirus Disease 2019 (COVID-19) Intensive Care Unit (ICU) Load and Demand at an Example Facility
Black solid vertical line with arrows indicates the numbers at 1 time point used to calculate COVID-19 ICU load, defined as the mean number of patients with COVID-19 in the ICU during a patient’s hospital stay divided by the number of ICU beds. Black dotted vertical line indicates the numbers at 1 time point used to calculate COVID-19 demand, defined as the mean number of patients with COVID-19 in the ICU during a patient’s hospital stay divided by the maximum number of patients with COVID-19 in the ICU during the study period. The results suggest that the risk of mortality would be highest if a COVID-19 patient’s stay was during the peak of ICU demand and if ICU caseload approached or exceeded ICU bed capacity.
Figure 2.
Figure 2.. Patient Flow Diagram
The figure displays the relative proportion of veterans with coronavirus disease 2019 (COVID-19) who were cared for in the general ward and intensive care unit (ICU).
See this image and copyright information in PMC

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