The role of organizational characteristics on the outcome of COVID-19 patients admitted to the ICU in Belgium

Fabio Silvio Taccone; Nina Van Goethem; Robby De Pauw; Xavier Wittebole; Koen Blot; Herman Van Oyen; Tinne Lernout; Marion Montourcy; Geert Meyfroidt; Dominique Van Beckhoven; Belgian Society of Intensive Care Medicine and the Belgian Collaborative Group on COVID-19 Hospital Surveillance

doi:10.1016/j.lanepe.2020.100019

The role of organizational characteristics on the outcome of COVID-19 patients admitted to the ICU in Belgium

Lancet Reg Health Eur. 2020 Dec 23:2:100019. doi: 10.1016/j.lanepe.2020.100019. eCollection 2021 Mar.

Affiliations

¹ Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
² Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium.
³ Department of Intensive Care, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium.
⁴ Department of Public Health and Primary Care, University of Gent, Gent, Belgium.
⁵ Department of Intensive Care Medicine, University of Leuven, Leuven, Belgium.

Abstract

Background: Several studies have investigated the predictors of in-hospital mortality for COVID-19 patients who need to be admitted to the Intensive Care Unit (ICU). However, no data on the role of organizational issues on patients' outcome are available in this setting. The aim of this study was therefore to assess the role of surge capacity organisation on the outcome of critically ill COVID-19 patients admitted to ICUs in Belgium.

Methods: We conducted a retrospective analysis of in-hospital mortality in Belgian ICU COVID-19 patients via the national surveillance database. Non-survivors at hospital discharge were compared to survivors using multivariable mixed effects logistic regression analysis. Specific analyses including only patients with invasive ventilation were performed. To assess surge capacity, data were merged with administrative information on the type of hospital, the baseline number of recognized ICU beds, the number of supplementary beds specifically created for COVID-19 ICU care and the "ICU overflow" (i.e. a time-varying ratio between the number of occupied ICU beds by confirmed and suspected COVID-19 patients divided by the number of recognized ICU beds reserved for COVID-19 patients; ICU overflow was present when this ratio is ≥ 1.0).

Findings: Over a total of 13,612 hospitalised COVID-19 patients with admission and discharge forms registered in the surveillance period (March, 1 to August, 9 2020), 1903 (14.0%) required ICU admission, of whom 1747 had available outcome data. Non-survivors (n = 632, 36.1%) were older and had more frequently various comorbid diseases than survivors. In the multivariable analysis, ICU overflow, together with older age, presence of comorbidities, shorter delay between symptom onset and hospital admission, absence of hydroxychloroquine therapy and use of invasive mechanical ventilation and of ECMO, was independently associated with an increased in-hospital mortality. Similar results were found in in in the subgroup of invasively ventilated patients. In addition, the proportion of supplementary beds specifically created for COVID-19 ICU care to the previously existing total number of ICU beds was associated with increased in-hospital mortality among invasively ventilated patients. The model also indicated a significant between-hospital difference in in-hospital mortality, not explained by the available patients and hospital characteristics.

Interpretation: Surge capacity organisation as reflected by ICU overflow or the creation of COVID-19 specific supplementary ICU beds were found to negatively impact ICU patient outcomes.

Funding: No funding source was available for this study.

Keywords: COVID-19; Intensive care unit; Mortality; Organisation; Surge.