COVID-19 Outcomes in Critically Ill Patients in New York City

In patients admitted to the hospital with coronavirus disease 2019 (COVID-19) in New York City, critical illness is common and associated with poor outcomes, according to the results of a prospective study published in The Lancet.

Researchers prospectively identified adult patients who were admitted to 2 New York Presbyterian hospitals affiliated with Columbia University Irving Medical Center in New York City, between March 2 and April 1, 2020, and were diagnosed with laboratory-confirmed COVID-19. The primary outcome was the rate of in-hospital mortality and secondary outcomes included the frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal replacement therapy, and time to in-hospital clinical deterioration after admission (defined as an increase of ≥1 point from baseline on a 7-point ordinal scale, as recommended by the World Health Organization).

A total of 1150 adults with COVID-19 were admitted to both hospitals, of whom 257 (22%) were critically ill. The median patient age was 62 years, 67% were men, and 82% had ≥1 chronic illness, the most common being diabetes and hypertension. Roughly half of the patients (46%) had obesity as defined by a body mass index ≥ 30 kg/m². The most common symptoms were shortness of breath, fever, cough, myalgia, and diarrhea.

As of April 28, 2020, a total of 257 (39%) patients had died after a median of 9 days in the hospital, including 84 of 203 patients who had received invasive mechanical ventilation. The median time to clinical deterioration after admission was 3 days and most deaths occurred in patients who were aged ≥50 years. A total of 94 patients remained hospitalized (median duration, 33 days) and 58 patients were discharged alive. Supplemental oxygen was necessary in 12 of the 58 patients and 4 were transferred to another facility. A total of 115 patients received noninvasive respiratory support via non-rebreathing oxygen face mask, 12 patients via high-flow nasal cannula, and 3 via noninvasive ventilation during hospitalization.

A total of 170 patients received vasopressors and 79 received renal replacement therapy during hospitalization. The median Sequential Organ Failure Assessment (SOFA) score was 11 (interquartile range, 8-13) on the first day of critical illness.

Older age (adjusted hazard ratio [aHR], 1.31 per 10-year increase), chronic cardiac disease (aHR, 1.76), chronic pulmonary disease (aHR, 2.94), higher concentrations of interleukin-6 (IL-6; aHR, 1.11), and higher concentrations of D-dimer (aHR, 1.10 per decile increase) were independently associated with in-hospital mortality in multivariable Cox modeling.

The researchers noted that the study may lack generalizability, given that it took place in 2 hospitals in a specific area of New York City. In addition, data were only collected through April 28, 2020, which means that the vital status of any patients who remained in the hospital beyond that date was not incorporated into the study. Therefore, the reported mortality rate of 39% represents the minimum in-hospital case fatality rate.

“Although the pathogenesis of severe COVID-19 remains to be completely understood, emerging data suggest that organ dysfunction and poor outcomes could be mediated by high concentrations of proinflammatory cytokines, including IL-6 and dysregulated coagulation and thrombosis,” the study authors wrote.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Cummings MJ, Baldwin MR, Abrams D, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study [published online May 19, 2020]. Lancet. doi:10.1016/S0140-6736(20)31189-2