Abstract
Reported mortality of hospitalised Coronavirus Disease-2019 (COVID-19) patients varies substantially, particularly in critically ill patients. So far COVID-19 in-hospital mortality and modes of death under state of the art care have not been systematically studied. This retrospective observational monocenter cohort study was performed after implementation of a non-restricted, dynamic tertiary care model at the University Medical Center Freiburg, an experienced acute respiratory distress syndrome (ARDS) and extracorporeal membrane-oxygenation (ECMO) referral center. All hospitalised patients with PCR-confirmed SARS-CoV-2 infection were included. The primary endpoint was in-hospital mortality, secondary endpoints included major complications and modes of death. A multistate analysis and a Cox regression analysis for competing risk models were performed. Modes of death were determined by two independent reviewers. Between February 25, and May 8, 213 patients were included in the analysis. The median age was 65 years, 129 patients (61%) were male. 70 patients (33%) were admitted to the intensive care unit (ICU), of which 57 patients (81%) received mechanical ventilation and 23 patients (33%) ECMO support. Using multistate methodology, the estimated probability to die within 90 days after COVID-19 onset was 24% in the whole cohort. If the levels of care at time of study entry were accounted for, the probabilities to die were 16% if the patient was initially on a regular ward, 47% if in the intensive care unit (ICU) and 57% if mechanical ventilation was required at study entry. Age ≥65 years and male sex were predictors for in-hospital death. Predominant complications-as judged by two independent reviewers-determining modes of death were multi-organ failure, septic shock and thromboembolic and hemorrhagic complications. In a dynamic care model COVID-19-related in-hospital mortality remained very high. In the absence of potent antiviral agents, strategies to alleviate or prevent the identified complications should be investigated. In this context, multistate analyses enable comparison of models-of-care and treatment strategies and allow estimation and allocation of health care resources.
Highlights
The current SARS-CoV-2 pandemic is a public health emergency of international concern, which poses immense challenges on health care systems [1]
COVID-19 in-hospital mortality and modes of death under state of the art care have not been systematically studied. This retrospective observational monocenter cohort study was performed after implementation of a non-restricted, dynamic tertiary care model at the University Medical Center Freiburg, an experienced acute respiratory distress syndrome (ARDS) and extracorporeal membrane-oxygenation (ECMO) referral center
Patients were treated on COVID-19 regular wards, COVID-19 intermediate care and intensive care units (ICU) run by different departments
Summary
The current SARS-CoV-2 pandemic is a public health emergency of international concern, which poses immense challenges on health care systems [1]. Modulated by host factors like age and comorbidities, overall about 10–15% of SARS-Cov-2 infected patients require hospitalisation and 20–30% of hospitalised patients develop critical or life-threatening COVID-19 manifestations [2]. Reported mortality rates of COVID-19 patients are in the range of 20–40% [1,3,4,5] for hospitalised patients and 30–88% for critically-ill or ICU patients with substantial differences between countries and regions [3,4,5,6,7,8,9,10]. Intensive care unit (ICU) and ventilation and extracorporeal membrane-oxygenation (ECMO) capacities may substantially vary, which may influence admission strategies and decisions on treatment withdrawal. Reported mortality of hospitalised Coronavirus Disease-2019 (COVID-19) patients varies substantially, in critically ill patients. COVID-19 in-hospital mortality and modes of death under state of the art care have not been systematically studied
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