ICU Mortality Across Prepandemic and Pandemic Cohorts in a Resource-Limited Setting: A Critical Care Resiliency Analysis From South Africa

George L Anesi; Stella M Savarimuthu; Jonathan Invernizzi; Robyn Hyman; Arisha Ramkillawan; Creaghan Eddey; Robert D Wise; Michelle T D Smith

doi:10.1016/j.chstcc.2023.100005

ICU Mortality Across Prepandemic and Pandemic Cohorts in a Resource-Limited Setting: A Critical Care Resiliency Analysis From South Africa

CHEST Crit Care. 2023 Jun;1(1):100005. doi: 10.1016/j.chstcc.2023.100005. Epub 2023 May 4.

Authors

George L Anesi¹, Stella M Savarimuthu², Jonathan Invernizzi³, Robyn Hyman³, Arisha Ramkillawan⁴, Creaghan Eddey⁴, Robert D Wise^{5

6

7}, Michelle T D Smith^{4

5}

Affiliations

¹ Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
² Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT.
³ Department of Anaesthesia and Critical Care, Harry Gwala Regional Hospital, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg.
⁴ Department of Anaesthesia and Critical Care, Greys Hospital, KwaZulu-Natal Department of Health, Pietermaritzburg.
⁵ Department of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.
⁶ Faculty Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.
⁷ Intensive Care Department, John Radcliffe Hospital, Oxford University Trust Hospitals, Oxford, England.

Abstract

Background: Hospital adaptation and resiliency, required during public health emergencies to optimize outcomes, are understudied especially in resource-limited settings.

Research question: What are the prepandemic and pandemic critical illness outcomes in a resource-limited setting and in the context of capacity strain?

Study design and methods: We performed a retrospective cohort study among patients admitted to ICUs at two public hospitals in the KwaZulu-Natal Department of Health in South Africa preceding and during the COVID-19 pandemic (2017-2022). We used multivariate logistic regression to analyze the association between three patient cohorts (prepandemic non-COVID-19, pandemic non-COVID-19, and pandemic COVID-19) and ICU capacity strain and the primary outcome of ICU mortality.

Results: Three thousand two hundred twenty-one patients were admitted to the ICU during the prepandemic period and 2,539 patients were admitted to the ICU during the pandemic period (n = 375 [14.8%] with COVID-19 and n = 2,164 [85.2%] without COVID-19). The prepandemic and pandemic non-COVID-19 cohorts were similar. Compared with the non-COVID-19 cohorts, the pandemic COVID-19 cohort showed older age, higher rates of chronic cardiovascular disease and diabetes, less extrapulmonary organ dysfunction, and longer ICU length of stay. Compared with the prepandemic non-COVID-19 cohort, the pandemic non-COVID-19 cohort showed similar odds of ICU mortality (OR, 1.06; 95% CI, 0.90-1.25; P = .50) whereas the pandemic COVID-19 cohort showed significantly increased odds of ICU mortality (OR, 3.91; 95% CI, 3.03-5.05 P < .0005). ICU occupancy was not associated with ICU mortality in either the COVID-19 cohort (OR, 1.05 per 10% change in ICU occupancy; 95% CI, 0.96-1.14; P = .27) or the pooled non-COVID-19 cohort (OR, 1.01 per 10% change in ICU occupancy; 95% CI, 0.98-1.03; P = .52).

Interpretation: Patients admitted to the ICU before and during the pandemic without COVID-19 were broadly similar in clinical characteristics and outcomes, suggesting critical care resiliency, whereas patients admitted to the ICU with COVID-19 showed important clinical differences and significantly higher mortality.

Keywords: COVID-19; capacity strain; hospital adaptation; hospital resiliency; preparedness.

Grants and funding

K23 HL161353/HL/NHLBI NIH HHS/United States