Cohort of Four Thousand Four Hundred Four Persons Under Investigation for COVID-19 in a New York Hospital and Predictors of ICU Care and Ventilation

Abstract

Study objective: Most coronavirus disease 2019 (COVID-19) reports have focused on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients. However, at initial presentation, most patients' viral status is unknown. Determination of factors that predict initial and subsequent need for ICU and invasive mechanical ventilation is critical for resource planning and allocation. We describe our experience with 4,404 persons under investigation and explore predictors of ICU care and invasive mechanical ventilation at a New York COVID-19 epicenter.Methods: We conducted a retrospective cohort study of all persons under investigation and presenting to a large academic medical center emergency department (ED) in New York State with symptoms suggestive of COVID-19. The association between patient predictor variables and SARS-CoV-2 status, ICU admission, invasive mechanical ventilation, and mortality was explored with univariate and multivariate analyses.Results: Between March 12 and April 14, 2020, we treated 4,404 persons under investigation for COVID-19 infection, of whom 68% were discharged home, 29% were admitted to a regular floor, and 3% to an ICU. One thousand six hundred fifty-one of 3,369 patients tested have had SARS-CoV-2-positive results to date. Of patients with regular floor admissions, 13% were subsequently upgraded to the ICU after a median of 62 hours (interquartile range 28 to 106 hours). Fifty patients required invasive mechanical ventilation in the ED, 4 required out-of-hospital invasive mechanical ventilation, and another 167 subsequently required invasive mechanical ventilation in a median of 60 hours (interquartile range 26 to 99) hours after admission. Testing positive for SARS-CoV-2 and lower oxygen saturations were associated with need for ICU and invasive mechanical ventilation, and with death. High respiratory rates were associated with the need for ICU care. Conclusion:Persons under investigation for COVID-19 infection contribute significantly to the health care burden beyond those ruling in for SARS-CoV-2. For every 100 admitted persons under investigation, 9 will require ICU stay, invasive mechanical ventilation, or both on arrival and another 12 within 2 to 3 days of hospital admission, especially persons under investigation with lower oxygen saturations and positive SARS-CoV-2 swab results. This information should help hospitals manage the pandemic efficiently. [

Continued In-Hospital Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use in Hypertensive COVID-19 Patients Is Associated With Positive Clinical Outcome

“…The prevalence of diabetes mellitus was higher in those in the ACEi/ARB group ( P = .01) but lower in those with chronic kidney disease (CKD) at baseline ( P = .001), whereas the prevalence of asthma, history of coronary heart disease, chronic obstructive pulmonary disease, and cancer were not significantly different between groups ( P > .05). Note that the prevalence of CKD in our hypertensive COVID-19 patient cohort was higher than that for all COVID-19 patients in general [ 27 ] as expected.…”

Inflammatory markers are poorly predictive of clinical outcomes among hospitalized patients with COVID-19

“…Our population consisted largely of African-Americans and Hispanics living in a socioeconomically depressed urban area, with very high endemic rates of chronic conditions such as hypertension and diabetes. Our population was thus dissimilar even to other populations within our broad geographic region [ 16 , 17 ]. There is an urgent need to focus more attention on this vulnerable population.…”

Characteristics and Outcomes of Individuals With Pre-existing Kidney Disease and COVID-19 Admitted to Intensive Care Units in the United States

“…Model 1 assesses the association of outcomes and underlying kidney disease overall, while model 2 assesses the association of outcomes and underlying kidney disease independent of comorbid conditions known to associate with COVID-19 outcomes. 17 , 21 , 31 , 32 , 33 , 34 , 35 Using analogous methods, we performed separate sensitivity analyses excluding patients on therapeutic-level anticoagulation on ICU day 1 from models examining major bleed and thromboembolic events, and excluding patients with histories of liver disease from models examining acute liver injury.…”

“…COVID-19-related critical illness affects w10% of patients hospitalized with COVID-19 and has an exceedingly high mortality rate. [14][15][16][17] Data from the United States indicate that patients with critical COVID-19 illness complicated by acute kidney injury have worse outcomes than those without acute kidney injury. [18][19][20][21] Single-center and regional studies suggest similarly poor outcomes among individuals with critical 1 2 3 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 COVID-19 illness and a pre-existing reduction in kidney function, especially kidney failure treated by maintenance dialysis, but sample sizes were limited and most lacked comparator populations.…”

“…COVID-19-related critical illness affects ∼10% of patients hospitalized with COVID-19 and has an exceedingly high mortality rate. 14 , 15 , 16 , 17 Data from the United States (U.S.) indicate that patients with critical COVID-19 illness complicated by acute kidney injury (AKI) have worse outcomes than those without AKI. 18 , 19 , 20 , 21 Single-center and regional studies suggest similarly poor outcomes among individuals with critical COVID-19 illness and pre-existing kidney dysfunction, especially dialysis-dependent kidney failure, but sample sizes were limited, and most lacked comparator populations.…”