People in intensive care with COVID-19: demographic and clinical features during the first, second, and third pandemic waves in Australia

The relationship between administratively recorded ethnicity and outcomes for people admitted to Australian intensive care units with COVID-19

BACKGROUND

The relationship between ethnicity and mortality of patients critically ill with COVID-19 in Australia has not been described. Defining those communities at the highest risk of severe COVID-19 may assist with formulating effective public health policy and may improve the equitable delivery of health care in Australia.

OBJECTIVE

The aim of this study was to describe the baseline characteristics, treatments, and outcomes of administratively recorded ethnic groups admitted to Australian intensive care units with confirmed COVID-19 infection.

METHODS

This was a retrospective, multicentre, cohort analysis of adult patients admitted primarily due to COVID-19 to the 78 intensive care units participating in the Short Period Incidence Study of Severe Acute Respiratory Infection Australia from February 2020 to May 2022. The main outcome measure was in-hospital mortality.

RESULTS

Of 4621 eligible patients admitted to intensive care units, the proportion of ethnic groups were White (38%), Middle Eastern (15%), Asian (10%), Other (10%), Aboriginal and Torres Strait Islander (3.3%), Black (1.1%), and Unknown (22%). Rates of vaccination, mechanical ventilation, and admission varied significantly between each group over the course of the pandemic (p < 0.01). However, after adjusting by age, body mass index, Acute Physiology And Chronic Health Evaluation II, the number of coexisting disorders, time from hospital to intensive care admission, vaccination, use of mechanical ventilation and centres, and week of admission as random effects, the only ethnicity independently associated with mortality was the "Other" group (risk difference: 5.27 [confidence interval: 0.54 to 10.01], p = 0.029).

CONCLUSION

This study demonstrates that the outcomes of patients critically ill with COVID-19 for most ethnic groups were broadly similar, with the exception of the "Other" group who had a higher in-hospital mortality rate.

A randomised, open-label trial of nebulised unfractionated heparin in patients mechanically ventilated for COVID-19

Nebulised unfractionated heparin (UFH) might reduce time to ventilator separation in patients with COVID-19 by reducing virus infectivity, pulmonary coagulopathy, and inflammation, but clinical trial data are limited. Between 1 July 2020 and 23 March 2022, we conducted, at two hospitals in Victoria, Australia, a randomised, parallel-group, open-label, controlled trial of nebulised UFH. Eligible patients were aged 18 years or more, intubated, under intensive care unit management, had a PaO2 to FIO2 ratio of 300 or less, had acute opacities affecting at least one lung quadrant and attributed to COVID-19, and were polymerase chain reaction-positive for SARS-CoV-2 or had further testing planned. The target sample size was 270, however, the trial was stopped due to slow recruitment. There were 50 enrolments, all of whom were analysed. The median age was 55 (interquartile range (IQR) 46-64) years, 28 (56%) were males, and 46 (92%) had acute respiratory distress syndrome. Twenty-seven (54%) were randomised to nebulised heparin and 23 (46%) to standard care. Nebulised UFH was administered to the heparin group on 6 (IQR 4-10) days; median daily dose of 83 (IQR 75-88) kIU. The primary outcome, time to separation from invasive ventilation to day 28 adjusted for the competing risk of death, was not significantly different between groups but took numerically longer in the nebulised heparin group (12.0, standard deviation (SD) 10.4 days versus 7.4, SD 6.9 days; hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.31 to 1.01, P = 0.052). One patient died by day 28 in each group, fewer than expected. Time to separation from invasive ventilation among survivors to day 28 occurred more quickly than expected in the standard care group and was, without correction for multiple comparisons, significantly slower in the heparin group (11.3, SD 10.0 days, n = 26 versus 6.4, SD 5.2 days, n = 22; HR 0.52, 95% CI 0.30 to 0.92, P = 0.024). Nebulised heparin did not reduce time to ventilator separation in intubated adult patients with COVID-19. The study is limited by the small sample size and potential for sampling bias. Further study is required.

In-hospital mortality in patients admitted to Australian intensive care units with COVID-19 between 2020 and 2024

Objective

To describe and compare the demographics, management, and outcomes for patients with COVID-19 admitted to intensive care units (ICUs) in Australia across the various waves of the COVID pandemic.

Design setting and participants

People aged ≥16 years who were admitted to a participating ICU with confirmed COVID-19 in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia study between February 2020 and May 2024.

Main outcome measures

Primary outcome: In-hospital mortality. Secondary outcomes: ICU mortality; ICU and hospital lengths of stay; supportive and disease-specific therapies.

Results

From 27 February 2020 to 18 May 2024, 10171 people were admitted to 72 ICUs with confirmed COVID-19 disease. The Wild Type wave included 518 (5.1%) patients, the Delta wave 2467 (24.3%) patients, and the Omicron wave 7186 (70.7%) patients. The median (IQR) age was 61 (49-70) years, 54 (41-66) years, and 65 (45-75) years, respectively (P < 0.001). The proportion of vaccinated cases increased in successive waves (1% vs 23.9% vs 65.1%) but plateaued in the Omicron subvariant waves (range 60.0%-71.9%). Invasive mechanical ventilation use decreased across successive waves (52.5% vs 43.6% vs 31.7%, P < 0.001). Use of extracorporeal membrane oxygenation was highest during the Delta wave (3.6%, 83 patients, median duration 18 days [IQR 9.8-35]). Multivariable analysis demonstrated an increased risk of in-hospital mortality among patients admitted during the Delta (adjusted HR 1.80, 95% CI: 1.38-2.35, p < 0.001) and Omicron (adjusted HR 1.88, 95% CI: 1.46-2.42, p < 0.001) waves when compared to the Wild Type wave.

Conclusion

COVID-19 continues to manifest significant morbidity and mortality in those requiring ICU admission. Despite a reduced need for ICU level supports, patients admitted during the Omicron wave demonstrated the highest in-hospital mortality.

Epidemiology of acute hypoxaemic respiratory failure in Australian and New Zealand intensive care units during 2005-2022. A binational, registry-based study

PURPOSE

Acute hypoxaemic respiratory failure (AHRF) is a common reason for intensive care unit (ICU) admission. However, patient characteristics, outcomes, and trends over time are unclear. We describe the epidemiology and outcomes of patients with AHRF over time.

METHODS

In this binational, registry-based study from 2005 to 2022, we included all adults admitted to an Australian or New Zealand ICU with an arterial blood gas within the first 24 h of ICU stay. AHRF was defined as a partial pressure of oxygen/inspired oxygen ratio (PaO2/FiO2) ≤ 300. The primary outcome was adjusted in-hospital mortality, categorised based on PaO2/FiO2 (mild: 200-300, moderate: 100-200, and severe < 100, and non-linearly). We investigated how adjusted mortality evolved based on temporal trends (by year of admission), sex, age, admission diagnosis and the receipt of mechanical ventilation.

RESULTS

Of 1,560,221 patients, 826,106 (52.9%) were admitted with or developed AHRF within the first 24 h of ICU stay. Of these 826,106 patients, 51.4% had mild, 39.3% had moderate, and 9.3% had severe AHRF. Compared to patients without AHRF (5.3%), patients with mild (8%), moderate (14.2%) and severe (29.9%) AHRF had higher in-hospital mortality rates. As PaO2/FiO2 ratio decreased, adjusted in-hospital mortality progressively increased, particularly below an inflection point at a PaO2/FiO2 ratio of 200. The adjusted in-hospital mortality for all patients decreased over time (13.3% in 2005 to 8.2% in 2022), and this trend was similar in patients with and without AHRF.

CONCLUSION

The healthcare burden due to AHRF may be larger than expected, and mortality rates remain high in severe AHRF. Although mortality has decreased over time, this may reflect improvements in ICU care in general, rather than specifically in AHRF. More research is required to earlier identify AHRF and stratify these patients at risk of deterioration early, and to validate our findings.

Prevalence, risk factors, and outcomes of secondary infections among hospitalized patients with COVID-19 or post-COVID-19 conditions in Victoria, 2020-2023

OBJECTIVES

Estimates of secondary infections are variedly reported, with few studies done in Australia. We investigated the occurrence and impact of secondary infections complicating COVID-19 and post-COVID-19 admissions in Victoria, Australia, 2020-2023.

METHODS

We used linked population-wide data sets and specific International Classification of Disease, 10th Revision codes to identify and estimate the occurrence of secondary infections. Using hospital/intensive care unit length of stay in negative binomial regression and mortality, we examined the impact of secondary infections.

RESULTS

Secondary infections were identified in 6.9% (13,467 of 194,660) of COVID-19 and post-COVID-19 admissions: 6.0% (11,651 of 194,660) bacterial, 0.9% (1691 of 194,660) viral, and 0.2% (385 of 194,660) fungal. Prevalence was highest during the pre-Delta (10.4%) and Omicron-BA2 (8.1%) periods. Sepsis and pneumonia were the most reported syndromes; the occurrence of sepsis declined gradually over time. The odds of secondary infections were higher among the ≥70-year-olds (adjusted odds ratio (aOR) 3.76, 95% confidence interval [CI] 3.43-4.14, vs 20-29-year-olds), individuals with chronic conditions (aOR 3.15, 95% CI 2.88-3.45, vs those without), the unvaccinated (aOR 1.59, 95% CI 1.45-1.75), and the lowest socioeconomic group (aOR 1.12, 95% CI 1.05-1.19). Patients with secondary infections had 2.43 times longer hospital length of stay and 9.60 times longer intensive care unit length of stay than those without secondary infections. The mortality risk was 2.17 times higher in those with secondary infections.

CONCLUSIONS

Secondary infections occurred in 69 per 1000 COVID-19-associated hospital admissions in Victoria, mostly in high-risk groups, and were associated with severe outcomes.

COVID-19 in a rural intensive care unit in Northern British Columbia: Descriptive analysis of outcomes and demands on rural resources

INTRODUCTION

This descriptive study reviews clinical outcomes of individuals admitted to a northern Canadian, rural intensive care unit (ICU) with severe COVID-19. It reports our site-specific data that is part of an ongoing global effort to gather data and guide therapy; the aims of this study were to describe participants admitted to our ICU with COVID-19 and illuminate challenges faced by rural and remote centres.

METHODS

This retrospective study examined data from participants admitted to the ICU with COVID-19 pneumonia between 24th November 2020 and 28th February 2022. Using data from electronic and hardcopy health records, data were obtained according to standardised forms developed for the Short Period Incidence Study of Severe Acute Respiratory Infection.

RESULTS

Eighty-five adult participants were admitted to our ICU with COVID-19. The median age of participants was 57 years old (range: 23-83 years); 49.4% were males and 50.6% were females. Of our cohort, 58.9% required mechanical ventilation at some point during their stay and the median duration of stay in our ICU was 5 days (range: 1-36 days). Amongst individuals included, 25.9% were discharged alive from our hospital on their index admission, 57.6% were transferred to another facility and 16.5% died in our facility.

CONCLUSION

COVID-19 significantly strained our local ICU resources, necessitating high numbers of patient transfers. However, despite limited resources, patients at our site received contemporary guideline-based care for COVID-19 pneumonia. Future pandemic and surge capacity planning must ensure that rural and remote communities receive adequate additional resources to meet the anticipated needs of their local populations.

INTRODUCTION

Cette étude descriptive examine les résultats cliniques des personnes admises dans une unité de soins intensifs rurale du nord du Canada avec une COVID-19 sévère. Elle rapporte des données spécifiques à notre site qui font partie d'un effort global en cours pour rassembler des données et guider la thérapie. Les objectifs de cette étude étaient de décrire les participants admis dans notre unité de soins intensifs avec la COVID-19 et d'éclairer les défis auxquels sont confrontés les centres ruraux et éloignés.

MTHODES

Cette étude rétrospective a examiné les données des participants admis à l'unité de soins intensifs pour une pneumonie due à la COIVD-19 entre le 24 novembre 2020 et le 28 février 2022. Les données ont été obtenues à partir de dossiers médicaux électroniques et papier, selon des formulaires standardisés développés pour l'étude d'incidence à court terme des infections respiratoires aiguës sévères (SPRINT-SARI).

RSULTATS

85 participants adultes ont été admis dans notre unité de soins intensifs avec la COVID-19. L'âge médian des participants était de 57 ans (intervalle: 23-83 ans); 49,4% étaient des hommes et 50,6% des femmes. Dans notre cohorte, 58,9% ont eu besoin d'une ventilation mécanique à un moment ou à un autre de leur séjour et la durée médiane du séjour dans notre unité de soins intensifs était de 5 jours (intervalle: 1-36 jours). Parmi les personnes incluses, 25,9% sont sorties vivantes de notre hôpital lors de leur admission initiale, 57,6% ont été transférées dans un autre établissement et 16,5% sont décédées dans notre établissement.

CONCLUSION

La COVID-19 a mis à rude épreuve les ressources de notre unité locale de soins intensifs, nécessitant un grand nombre de transferts de patients. Cependant, malgré des ressources limitées, les patients de notre site ont reçu des soins fondés sur des lignes directrices contemporaines pour la pneumonie due à la COVID-19. À l'avenir, la planification de la pandémie et de la capacité de pointe doit garantir que les communautés rurales et éloignées reçoivent des ressources supplémentaires adéquates pour répondre aux besoins anticipés de leurs populations locales.

Cardiovascular outcomes for people hospitalised with COVID-19 in Australia, and the effect of vaccination: an observational cohort study

OBJECTIVES

To assess the frequency of clinical cardiovascular outcomes for people hospitalised with coronavirus disease 2019 (COVID-19), and the impact of vaccination.

STUDY DESIGN

Observational cohort study.

SETTING, PARTICIPANTS

All index admissions of adults with laboratory-confirmed COVID-19 to 21 hospitals participating in the Australian Cardiovascular COVID-19 Registry (AUS-COVID), 4 September 2020 - 11 July 2022.

MAIN OUTCOME MEASURES

Frequency of elevated troponin levels, new arrhythmia, new or deteriorating heart failure or cardiomyopathy, new pericarditis or myocarditis, new permanent pacemaker or implantable cardioverter-defibrillator, and pulmonary embolism.

SECONDARY OUTCOMES

impact of COVID-19 vaccination on likelihood of in-hospital death, intubation, troponin elevation, and clinical cardiovascular events.

RESULTS

The mean age of the 1714 people admitted to hospital with COVID-19 was 60.1 years (standard deviation, 20.6 years); 926 were men (54.0%), 181 patients died during their index admissions (10.6%), 299 required intensive care (17.4%). Thirty-eight patients (2.6%) developed new atrial fibrillation or flutter, 27 (2.6%) had pulmonary embolisms, new heart failure or cardiomyopathy was identified in 13 (0.9%), and pre-existing cardiomyopathy or heart failure was exacerbated in 21 of 110 patients (19%). Troponin was elevated in 369 of the 986 patients for whom it was assessed (37.4%); in-hospital mortality was higher for people with elevated troponin levels (86, 23% v 23, 3.7%; P < 0.001). The COVID-19 vaccination status of 580 patients was known (no doses, 232; at least one dose, 348). The likelihood of in-hospital death (adjusted odds ratio [aOR], 0.38; 95% confidence interval [CI], 0.18-0.79) and intubation (aOR, 0.30; 95% CI, 0.15-0.61) were lower for people who had received at least one vaccine dose, but not the likelihood of troponin elevation (aOR, 1.44; 95% CI, 0.80-2.58) or clinical cardiovascular events (aOR, 1.56; 95% CI, 0.59-4.16).

CONCLUSIONS

Although troponin levels were elevated in a considerable proportion of people hospitalised with COVID-19, clinical cardiovascular events were infrequent, and their likelihood was not influenced by vaccination. COVID-19 vaccination, however, was associated with reduced likelihood of in-hospital death and intubation.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12620000486921 (prospective).

A retrospective descriptive study of medical record documentation of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds

INTRODUCTION

Communication between clinicians and family members of patients about treatment limitation practices is essential to care-planning and decision-making. For patients and family members from culturally diverse backgrounds, there are additional considerations when communicating about treatment limitations.

OBJECTIVE

The objective of this study was to explore how treatment limitations are communicated with family members of patients from culturally diverse backgrounds in intensive care.

METHODS

A descriptive study using a retrospective medical record audit was undertaken. Medical record data were collected from patients who died in 2018 in four intensive care units in Melbourne, Australia. Data are presented using descriptive and inferential statistics and progress note entries.

RESULTS

From 430 adult deceased patients, 49.3% (n = 212) of patients were born overseas, 56.9% (n = 245) identified with a religion, and 14.9% (n = 64) spoke a language other than English as their preferred language. Professional interpreters were used in 4.9% (n = 21) of family meetings. Documentation about the level of treatment limitation decisions were present in 82.1% (n = 353) of patient records. Nurses were documented as present for treatment limitation discussions for 49.3% (n = 174) of patients. Where nurses were present, nurses supported family members, including reassurance that end-of-life wishes would be respected. There was evidence of nurses coordinating healthcare activities and attempting to address and resolve difficulties experienced by family members.

CONCLUSIONS

This is the first known Australian study to explore documented evidence of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds. Many patients have documented treatment limitations, yet there are a proportion of patients who die before treatment limitations can be discussed with family, which may influence the timing and quality of end-of-life care. Where language barriers exist, interpreters should be used to better ensure effective communication between clinicians and family. Greater provision for nurses to engage in treatment limitation discussions is required.

Association between protocol change to a higher-protein formula with lower energy targets and nutrient delivery in critically ill patients with COVID-19: A retrospective cohort study

BACKGROUND

Guidelines recommend prioritizing protein provision while avoiding excessive energy delivery to critically ill patients with coronavirus disease 2019 (COVID-19), but there are no prospective studies evaluating such a targeted approach in this group. We aimed to evaluate the effect of a "higher-protein formula protocol" on protein, energy, and volume delivery when compared with standard nutrition protocol.

METHODS

This was a retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation for >72 h and enteral nutrition. Before October 2021, the standard nutrition protocol for patients was 0.7 ml/kg/h ideal body weight (IBW) of a 63 g/L protein and 1250 kcal/L formula. From October 2021, we implemented a higher-protein formula protocol for patients with COVID-19. The initial prescription was 0.5 ml/kg/h IBW of a 100 g/L protein and 1260 kcal/L formula with greater emphasis on energy targets being directed by indirect calorimetry when possible. Measured outcomes included protein, energy, and volume delivered.

RESULTS

There were 114 participants (standard protocol, 48; higher-protein protocol, 66) with 1324 days of nutrition support. The median (95% CI) differences in protein, energy, and volume delivery between targeted and standard protocol periods were 0.08 g/kg/day (-0.02 to 0.18 g/kg/day), -1.71 kcal/kg/day (-3.64 to 0.21 kcal/kg/day) and -1.5 ml/kg/day (-2.9 to -0.1 ml/kg/day). Thirty-three patients (standard protocol, 7; higher-protein protocol, 26) had 44 indirect calorimetry assessments. There was no difference in measured energy expenditure over time (increased by 0.49 kcal/kg/day [-0.89 to 1.88 kcal/kg/day]).

CONCLUSION

Implementation of a higher-protein formula protocol to patients with COVID-19 modestly reduced volume administration without impacting protein and energy delivery.

Impact of frailty on long-term survival in patients discharged alive from hospital after an ICU admission with COVID-19

Objective

Though frailty is associated with mortality, its impact on long-term survival after an ICU admission with COVID-19 is unclear. We aimed to investigate the association between frailty and long-term survival in patients after an ICU admission with COVID-19.

Design Setting and Participants

This registry-based multicentre, retrospective, cohort study included all patients ≥16 years discharged alive from the hospital following an ICU admission with COVID-19 and documented clinical frailty scale (CFS). Data from 118 ICUs between 01/01/2020 through 31/12/2020 in New Zealand and 31/12/2021 in Australia were reported in the Australian and New Zealand Intensive Care Society Adult Patient Database. The patients were categorised as 'not frail' (CFS 1-3), 'mildly frail' (CFS 4-5) and 'moderately-to-severely frail' (CFS 6-8).

Main Outcome Measures

The primary outcome was survival time up to two years, which we analysed using Cox regression models.

Results

We included 4028 patients with COVID-19 in the final analysis. 'Moderately-to-severely frail' patients were older (66.6 [56.3-75.8] vs. 69.9 [60.3-78.1]; p < 0.001) than those without frailty (median [interquartile range] 53.0 [40.1-64.6]), had higher sequential organ failure assessment scores (p < 0.001), and less likely to receive mechanical ventilation (p < 0.001) than patients without frailty or mild frailty. After adjusting for confounders, patients with mild frailty (adjusted hazards ratio: 2.31, 95%-CI: 1.75-3.05) and moderate-to-severe frailty (adjusted hazards ratio: 2.54, 95%-CI: 1.89-3.42) had higher mortality rates than those without frailty.

Conclusions

Frailty was independently associated with shorter survival times to two years in patients with severe COVID-19 in ANZ following hospital discharge. Recognising frailty provides individualised patient intervention in those with frailty admitted to ICUs with severe COVID-19.

Clinical trial registration

Not applicable.

Magnitude and time to peak oxygenation effect of prone positioning in ventilated adults with COVID-19 related acute hypoxemic respiratory failure

BACKGROUND

Prone positioning may improve oxygenation in acute hypoxemic respiratory failure and was widely adopted in COVID-19 patients. However, the magnitude and timing of its peak oxygenation effect remain uncertain with the optimum dosage unknown. Therefore, we aimed to investigate the magnitude of the peak effect of prone positioning on the PaO2 :FiO2 ratio during prone and secondly, the time to peak oxygenation.

METHODS

Multi-centre, observational study of invasively ventilated adults with acute hypoxemic respiratory failure secondary to COVID-19 treated with prone positioning. Baseline characteristics, prone positioning and patient outcome data were collected. All arterial blood gas (ABG) data during supine, prone and after return to supine position were analysed. The magnitude of peak PaO2 :FiO2 ratio effect and time to peak PaO2 :FIO2 ratio effect was measured.

RESULTS

We studied 220 patients (mean age 54 years) and 548 prone episodes. Prone positioning was applied for a mean (±SD) 3 (±2) times and 16 (±3) hours per episode. Pre-proning PaO2 :FIO2 ratio was 137 (±49) for all prone episodes. During the first episode. the mean PaO2 :FIO2 ratio increased from 125 to a peak of 196 (p < .001). Peak effect was achieved during the first episode, after 9 (±5) hours in prone position and maintained until return to supine position.

CONCLUSIONS

In ventilated adults with COVID-19 acute hypoxemic respiratory failure, peak PaO2 :FIO2 ratio effect occurred during the first prone positioning episode and after 9 h. Subsequent episodes also improved oxygenation but with diminished effect on PaO2 :FIO2 ratio. This information can help guide the number and duration of prone positioning episodes.

The Western Australian experience of COVID-19 after the borders reopened: evaluation of public health modelling predictions

BACKGROUND

Western Australia (WA) serves as a unique global case study on the impact of coronavirus disease 2019 (COVID-19) on an isolated, prepared and highly vaccinated population. This study builds upon the study performed by House et al. through an extended data set.

AIM

To examine the impact of COVID-19 at the only quaternary hospital in WA following the border opening from 3 March to 17 July 2022.

PARTICIPANTS

A total of 257 adults were admitted with COVID-19 under either respiratory or the intensive care unit (ICU).

OUTCOMES

Admission numbers, disease severity, ICU admission, prevalence of COVID-19 deterioration risk factors, length of stay and mortality.

RESULTS

A total of 257 patients were admitted with COVID-19, under respiratory (81.7%) and ICU (18.3%). COVID-19 was the primary reason for admission for 67.7%. Ten patients died during the study, with seven deaths attributed to COVID pneumonitis. COVID-19 severity was 37.4% mild, 37.0% moderate, 18.3% severe and 7.4% critical. Risk factors for requiring ICU included incomplete immunisation status (P = 0.011), chronic kidney disease (P = 0.008) and Aboriginal and Torres Strait Islander (ATSI) ethnicity. The WA Department of Health predicted that the number of hospitalisations and ICU cases were significantly higher than the actual number of cases.

CONCLUSION

The number of hospitalisations and ICU COVID-19 cases were significantly less than predicted, likely due to high population vaccination rates prior to border opening. The main risk factors for COVID-19 severity were incomplete immunisation and ATSI ethnicity.

Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19

PURPOSE

Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain.

METHODS

Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position.

RESULTS

We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001).

CONCLUSION

During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.

Characteristics and outcome of COVID-19 patients admitted to the ICU: a nationwide cohort study on the comparison between the consecutive stages of the COVID-19 pandemic in the Netherlands, an update

BACKGROUND

Previously, we reported a decreased mortality rate among patients with COVID-19 who were admitted at the ICU during the final upsurge of the second wave (February-June 2021) in the Netherlands. We examined whether this decrease persisted during the third wave and the phases with decreasing incidence of COVID-19 thereafter and brought up to date the information on patient characteristics.

METHODS

Data from the National Intensive Care Evaluation (NICE)-registry of all COVID-19 patients admitted to an ICU in the Netherlands were used. Patient characteristics and rates of in-hospital mortality (the primary outcome) during the consecutive periods after the first wave (periods 2-9, May 25, 2020-January 31, 2023) were compared with those during the first wave (period 1, February-May 24, 2020).

RESULTS

After adjustment for patient characteristics and ICU occupancy rate, the mortality risk during the initial upsurge of the third wave (period 6, October 5, 2021-January, 31, 2022) was similar to that of the first wave (ORadj = 1.01, 95%-CI [0.88-1.16]). The mortality rates thereafter decreased again (e.g., period 9, October 5, 2022-January, 31, 2023: ORadj = 0.52, 95%-CI [0.41-0.66]). Among the SARS-CoV-2 positive patients, there was a huge drop in the proportion of patients with COVID-19 as main reason for ICU admission: from 88.2% during the initial upsurge of the third wave to 51.7%, 37.3%, and 41.9% for the periods thereafter. Restricting the analysis to these patients did not modify the results on mortality.

CONCLUSIONS

The results show variation in mortality rates among critically ill COVID-19 patients across the calendar time periods that is not explained by differences in case-mix and ICU occupancy rates or by varying proportions of patients with COVID-19 as main reason for ICU admission. The consistent increase in mortality during the initial, rising phase of each separate wave might be caused by the increased virulence of the contemporary virus strain and lacking immunity to the new strain, besides unmeasured patient-, treatment- and healthcare system characteristics.

Thrombo-inflammatory response in hospitalised patients with COVID-19: a single institution experience

BACKGROUND

Severe COVID-19 causes acute inflammation, which is complicated by venous thromboembolism events (VTE). However, it is unclear if VTE risk has evolved over time since the COVID-19 outbreak.

AIMS

To determine markers of thrombo-inflammation and rates of symptomatic VTE in patients hospitalised for COVID-19 in a metropolitan hospital in Sydney, Australia.

METHODS

A retrospective, single-centre, cohort study was performed by reviewing electronic medical records of consecutive patients admitted to Royal Prince Alfred Hospital between March 2020 and September 2021. This period included three waves of COVID-19 outbreaks in Australia with the ancestral, alpha and delta variants. Standard coagulation assays and inflammatory markers were recorded over 4 weeks.

RESULTS

A total of 205 patients were consecutively admitted during the study period. Activated partial thromboplastin time, neutrophil count and C-reactive protein (CRP) were significantly increased in patients hospitalised in the intensive care unit (ICU) compared with non-ICU patients. The use of anti-inflammatory medication increased in 2021 compared with 2020. The mortality rate was 7.3% in our cohort. Ninety-four per cent of patients received anticoagulation with 6.3% of patients developing VTE.

CONCLUSION

We observed lower rates of VTE compared to the internationally reported rate for the same period. We conclude that in the setting of controlled hospital admission rate and standard anticoagulation guidelines, COVID-19 resulted in similar thrombo-inflammatory response and VTE rates over the first 1.5 years of the pandemic.

The impact of body mass index on long-term survival after ICU admission due to COVID-19: A retrospective multicentre study

Objective

The impact of obesity on long-term survival after intensive care unit (ICU) admission with severe coronavirus disease 2019 (COVID-19) is unclear. We aimed to quantify the impact of obesity on time to death up to two years in patients admitted to Australian and New Zealand ICUs.

Design

Retrospective multicentre study.

Setting

92 ICUs between 1st January 2020 through to 31st December 2020 in New Zealand and 31st March 2022 in Australia with COVID-19, reported in the Australian and New Zealand Intensive Care Society adult patient database.

Participants

All patients with documented height and weight to estimate the body mass index (BMI) were included. Obesity was classified patients according to the World Health Organization recommendations.

Interventions and main outcome measures

The primary outcome was survival time up to two years after ICU admission. The effect of obesity on time to death was assessed using a Cox proportional hazards model. Confounders were acute illness severity, sex, frailty, hospital type and jurisdiction for all patients.

Results

We examined 2,931 patients; the median BMI was 30.2 (IQR 25.6-36.0) kg/m2. Patients with a BMI ≥30 kg/m2 were younger (median [IQR] age 57.7 [46.2-69.0] vs. 63.0 [50.0-73.6]; p < 0.001) than those with a BMI <30 kg/m2. Most patients (76.6%; 2,244/2,931) were discharged alive after ICU admission. The mortality at two years was highest for BMI categories <18.5 kg/m2 (35.4%) and 18.5-24.9 kg/m2 (31.1%), while lowest for BMI ≥40 kg/m2 (14.5%). After adjusting for confounders and with BMI 18.5-24.9 kg/m2 category as a reference, only the BMI ≥40 kg/m2 category patients had improved survival up to 2 years (hazard ratio = 0.51; 95%CI: 0.34-0.76).

Conclusions

The obesity paradox appears to exist beyond hospital discharge in critically ill patients with COVID-19 admitted in Australian and New Zealand ICUs. A BMI ≥40 kg/m2 was associated with a higher survival time of up to two years.

Workers' compensation claims for COVID-19 among workers in healthcare and other industries during 2020-2022, Victoria, Australia

OBJECTIVE

To identify and characterise COVID-19 workers' compensation claims in healthcare and other industries during the pandemic in Victoria, Australia.

METHODS

We used workers' compensation claims identified as COVID-19 infection related from 1 January 2020 to 31 July 2022 to compare COVID-19 infection claims and rates of claims by industry and occupation, and in relation to Victorian COVID-19 epidemiology. A Cox proportional hazards model assessed risk factors for extended claim duration.

RESULTS

Of the 3313 direct and indirect COVID-19-related claims identified, 1492 (45.0%) were classified as direct COVID-19 infection accepted time-loss claims and were included in analyses. More than half (52.9%) of COVID-19 infection claims were made by healthcare and social assistance industry workers, with claims for this group peaking in July-October 2020. The overall rate of claims was greater in the healthcare and social assistance industry compared with all other industries (16.9 vs 2.4 per 10 000 employed persons) but industry-specific rates were highest in public administration and safety (23.0 per 10 000 employed persons). Workers in healthcare and social assistance were at increased risk of longer incapacity duration (median 26 days, IQR 16-61 days) than in other industries (median 17 days, IQR 11-39.5 days).

CONCLUSIONS

COVID-19 infection claims differed by industry, occupational group, severity and timing and changes coincided with different stages of the COVID-19 pandemic. Occupational surveillance for COVID-19 cases is important and monitoring of worker's compensation claims and incapacity duration can contribute to understanding the impacts of COVID-19 on work absence.

The PhLIP team: Feasibility of a physiotherapy-led intensive prone positioning team initiative during the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of patients with refractory hypoxaemic respiratory failure being admitted to the intensive care unit (ICU). Prone positioning can improve oxygenation but requires a team of skilled personnel to complete safely. Critical care physiotherapists (PTs) are ideally suited to lead proning teams, due to their expertise in moving critically unwell, invasively ventilated patients.

OBJECTIVES

The aim of this study was to describe the feasibility of implementing a physiotherapy-led intensive proning (PhLIP) team to support the critical care team during surges.

METHODS

This study involves descriptive evaluation of feasibility and implementation of the PhLIP team, a novel model of care, during the Delta wave of the COVID-19 pandemic, through a retrospective, observational audit of PhLIP team activity, ICU clinical activity, and a description of clinical outcomes.

RESULTS

Between 17 September and 19 November 2021, 93 patients with COVID-19 were admitted to the ICU. Fifty-one patients (55%) were positioned prone, a median [interquartile range] 2 [2, 5] times, for a mean (±standard deviation) duration of 16 (±2) h, across 161 episodes. Twenty-three PTs were upskilled and deployed to the PhLIP team, adding 2.0 equivalent full time to the daily service. Ninety-four percent of prone episodes (154) were led by the PhLIP PTs with a median 4 [interquartile range: 2, 8] turns per day. Potential airway adverse events occurred on three occasions (1.8%) and included an endotracheal tube leak, displacement, and obstruction. Each incident was promptly managed without prolonged impact on the patient. No manual handling injuries were reported.

CONCLUSION

The implementation of a physiotherapy-led proning team was safe and feasible and can release critical care-trained medical and nursing staff to other duties in the ICU.

The unique COVID-19 experience in Western Australia: lessons learnt

BACKGROUND

Western Australia (WA) was in a unique position to experience coronavirus disease 2019 (COVID-19) in a highly vaccinated and geographically isolated population.

AIM

To describe the COVID-19 Omicron experience at the only quaternary hospital in WA following border opening from 3 March to 11 May 2022.

PARTICIPANTS

A total of 158 adults with microbiologically confirmed COVID-19 were admitted to the respiratory or intensive care unit (ICU).

OUTCOMES

Admission numbers, disease severity, prevalence of COVID-19 deterioration risk factors, immunisation status, severity of infection, immunosuppression and treatment regimen.

RESULTS

One hundred fifty-eight COVID-19-positive patients were admitted to the respiratory ward (n = 123) and the ICU (n = 35) during the study period. COVID-19 infection was the primary admission reason in 32.9% of patients, 51.3% were male and the median age was 62 years. Aboriginal or Torres Strait Islanders (ATSI) were overrepresented (13.3%). Care was predominantly ward based (77.2%). Nearly half of the patients had mild COVID-19 (49.4%). Dexamethasone was the most common treatment provided to patients (58.2%). The median length of stay was 5.8 days (interquartile range, 5-15). Eight patients died during the study period (5.1%), with three of those deaths attributable to COVID-19.

CONCLUSIONS

COVID-19 case numbers following WA state border opening were of lower care acuity and disease severity than predicted. Two-thirds of admissions were for other primary diagnoses, with incidental COVID detection. Hospital admissions were overrepresented by partially or unvaccinated patients and by ATSI Australians. An increase in social support along with general and geriatric medicine speciality input were required to treat hospitalised COVID-19 cases in the WA Omicron wave.

Mortality among people admitted to Australian intensive care units for reasons other than COVID-19 during the COVID-19 pandemic: a retrospective cohort study

OBJECTIVE

To investigate in-hospital mortality among people admitted to Australian intensive care units (ICUs) with conditions other than coronavirus disease 2019 (COVID-19) during the COVID-19 pandemic.

DESIGN

National, multicentre, retrospective cohort study; analysis of data in the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) Adult Patient Database.

SETTING, PARTICIPANTS

Adults (16 years or older) without COVID-19 admitted to Australian ICUs, 1 January 2016 - 30 June 2022.

MAIN OUTCOME MEASURES

All-cause in-hospital mortality, unadjusted and relative to the January 2016 value, adjusted for illness severity (Australian and New Zealand Risk of Death [ANZROD] and hospital type), with ICU as a random effect. Points of change in mortality trends (breakpoints) were identified by segmental regression analysis.

RESULTS

Data for 950 489 eligible admissions to 186 ICUs were available. In-hospital mortality declined steadily from January 2016 to March 2021 by 0.3% per month (P < 0.001; March 2021 v January 2016: adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.62-0.80), but rose by 1.4% per month during March 2021 - June 2022 (P < 0.001; June 2022 v January 2016: aOR, 1.03; 95% CI, 0.90-1.17). The rise in mortality continued after the number of COVID-19-related ICU admissions had declined; mortality increased in jurisdictions with lower as well as in those with higher numbers of COVID-19-related ICU admissions.

CONCLUSION

The rise in in-hospital mortality among people admitted to Australian ICUs with conditions other than COVID-19 from March 2021 reversed the improvement of the preceding five years. Changes to health service delivery during the pandemic and their consequences should be investigated further.

Inter-hospital transfer and clinical outcomes for people with COVID-19 admitted to intensive care units in Australia: an observational cohort study

OBJECTIVES

To examine the association between inter-hospital transfer and in-hospital mortality among people with coronavirus disease 2019 (COVID-19) admitted to intensive care units (ICUs) in Australia.

DESIGN

Retrospective cohort study; analysis of data collected for the Short Period Incidence Study of Severe Acute Respiratory Illness (SPRINT-SARI) Australia study.

SETTING, PARTICIPANTS

People with COVID-19 admitted to 63 ICUs, 1 January 2020 - 1 April 2022.

MAIN OUTCOME MEASURES

Primary outcome: in-hospital mortality; secondary outcomes: ICU and hospital lengths of stay and frequency of selected complications.

RESULTS

Of 5207 people with records in the SPRINT-SARI Australia database at 1 April 2022, 328 (6.3%) had been transferred between hospitals, 305 (93%) during the third pandemic wave. Compared with patients not transferred, their median age was lower (53 years; interquartile range [IQR], 45-61 years v 60 years; IQR, 46-70 years), their median body mass index higher (32.5 [IQR, 27.2-39.0] kg/m² v 30.1 [IQR, 25.7-35.7] kg/m² ), and fewer had received a COVID-19 vaccine (22% v 44.9%); their median APACHE II scores were similar (14.0; IQR, 12.0-18.0 v 14.0; IQR, 10.0-19.0). Bacterial pneumonia (64.7% v 29.0%) and bacteraemia (27% v 8%) were more frequent in transferred patients, as was the need for more intensive ICU interventions, including invasive mechanical ventilation (71.2% v 38.1%) and extra-corporeal membrane oxygenation (26% v 1.7%). Crude ICU (19% v 14.9%) and in-hospital mortality (19% v 18.4%) were similar for patients who were or were not transferred; median lengths of ICU (20.0 [IQR, 11.2-40.3] days v 4.6 [IQR, 2.1-10.1] days) and hospital stay (29.7 [IQR, 18.1-49.6] days v 12.3 [IQR, 7.3-21.0] days) were longer for transferred patients. In the multivariable regression analysis, in-hospital mortality risk was lower for transferred patients (risk difference [RD], -5.0 percentage points; 95% confidence interval [CI] -10 to -0.03 percentage points), but not in the propensity score-adjusted analysis (RD, -3.4 [95% CI, -8.9 to 2.1] percentage points).

CONCLUSIONS

Among people with COVID-19 admitted to ICUs, patients transferred from another hospital required more intense interventions and remained in hospital longer, but were not at greater risk of dying in hospital than the patients who were not transferred.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction

COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients.

Methods

Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain.

Results

424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713).

Conclusions

Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome.

Outcomes comparison between the first and the subsequent SARS-CoV-2 waves - a systematic review and meta-analysis

Background

In the beginning of the SARS-CoV-2 pandemic, health care professionals dealing with COVID-19 had to rely exclusively on general supportive measures since specific treatments were unknown. The subsequent waves could be faced with new diagnostic and therapeutic tools (e.g., anti-viral medications and vaccines). We performed a meta-analysis and systematic review to compare clinical endpoints between the first and subsequent waves.

Methods

Three databases were assessed. The primary outcome was in-hospital mortality. The secondary outcomes were intensive care unit (ICU) mortality, ICU length of stay (LOS), acute renal failure, extracorporeal membrane oxygenation (ECMO) implantation, mechanical ventilation time, hospital LOS, systemic thromboembolism, myocarditis and ventilator associated pneumonia.

Results

A total of 25 studies with 126,153 patients were included. There was no significant difference for the primary endpoint (OR=0.94, 95% CI 0.83-1.07, p=0.35). The first wave group presented higher rates of ICU LOS (SMD= 0.23, 95% CI 0.11-0.35, p<0.01), acute renal failure (OR=1.71, 95% CI 1.36-2.15, p<0.01) and ECMO implantation (OR=1.64, 95% CI 1.06-2.52, p=0.03). The other endpoints did not show significant differences.

Conclusions

The analysis suggests that the first wave group, when compared with the subsequent waves group, presented higher rates of ICU LOS, acute renal failure and ECMO implantation, without significant difference in in-hospital or ICU mortality, mechanical ventilation time, hospital LOS, systemic thromboembolism, myocarditis or ventilator- associated pneumonia.

Clinical Characteristics and Mortality-Associated Factors in COVID-19 Critical Patients in a Portuguese ICU

INTRODUCTION

Severe COVID-19 is associated with serious complications and poor outcomes. Older age and underlying comorbidities are known risk factors for severe COVID-19, but a better understanding of baseline characteristics and outcomes of patients with severe COVID-19 is urgently needed.

METHODS

This study was a retrospective case series of 227 consecutive patients with laboratory-confirmed COVID-19 admitted to the intensive care unit (ICU) at our institution between March 2020 and December 2021. Demographic and clinical data were collected.

RESULTS

The median age of patients was 65 years, and 180 (79.3%) were male. Cardiovascular comorbidities were frequent and included hypertension (n=148; 65.2%), dyslipidemia (n=116; 51.1%), obesity (n=114; 50.2%), and diabetes mellitus (n=80; 35.2%). About 20% of the patients had the chronic respiratory disease, with sleep apnea being the most common. Immunosuppression was identified in 13% of the patients, with autoimmunity, post-transplantation, and neoplasms being the most represented causes. Most patients were admitted to the ICU at six to 15 days after symptom onset, corresponding to stages IIb (pulmonary involvement/hypoxia) and III (hyperinflammatory). All patients received systemic steroids, with an average treatment duration of 22 days. Several ventilatory support strategies were used; 80 patients were supported entirely noninvasively with high flow nasal oxygenation and noninvasive ventilation, while 164 patients were invasively ventilated. Most intubations (65%) occurred in the first 24 hours after admission, and the mean duration of mechanical ventilation was 14 days. The reintubation rate was 10%, occurring on average two to three days after planned extubation. Thirty-two tracheostomies were performed. Bacterial co-infection was treated in 75% of patients, and Aspergillus co-infection complicating COVID-19 pneumonia was diagnosed in eight patients. Median ICU and hospital stays were 15 and 25 days, respectively, and the 28-day mortality rate was 38%. Patients over 75 years experienced a higher mortality rate (56%). Increased age and multimorbidity, particularly comprising cardiovascular disease and associated risk factors, were significantly more common in patients who died within 28 days after ICU admission.

CONCLUSIONS

A large proportion of critically ill COVID-19 patients required prolonged mechanical ventilation. ICU/hospital stay and mortality were particularly elevated in older patients and patients with cardiovascular risk factors. Considerable discrepancy existed between the proportion of patients with microbiological documentation of bacterial infections and those receiving antimicrobials. Improved methods for adequate microbiological diagnosis are needed and stewardship programs should be reinforced.