Lessons Must Be Learned from COVID-19 Critical Care Gains

Liam Davenport

October 28, 2021

There have been huge improvements in the outcomes of patients admitted to critical care with COVID-19 since the start of the pandemic, with the length of stay falling by an average of 4 days and mortality by 14%, show data presented at the Med+ 2021 conference on October 26.

While this has been achieved on the back of innovative landmark trials and an adaptive approach to guideline-based care, the benefits could be lost if we do not learn the lessons of these achievements, warned a leading clinician.

Dr Alison Pittard, dean, The Faculty of Intensive Care Medicine, London, said the recently published Intensive Care National Audit & Research Centre report on COVID-19 in critical care for England, Wales and Northern Ireland showed that profile of COVID-19 cases has shifted over time.

Pregnancy

Compared with the first wave of the pandemic, the average age at admission to critical care with COVID-19 since 1 May, 2021, has fallen, from 58.8 years to 52.5 years, while the proportion of female patients has risen, from 29.9% to 39.6%.

"That may be because we’re seeing more pregnant women," she said. The proportion of women admitted to critical care with COVID-19 who were pregnant rose from 8.9% to 29.9% during the pandemic.

The proportion of patients from the most deprived areas has also risen, from 26.0% to 34.5%, as has the proportion with a body mass index of 40 kg/m2 or over, from 8.0% to 13.2%.

However, Dr Pittard said that, based on Acute Physiology And Chronic Health Evaluation (APACHE) II scores, "patients aren’t quite as sick as they were in the first phase".

Capacity

While the proportion of hospitalised COVID-19 patients who end up in critical care has halved over the course of the pandemic, from 15% to 7%, Dr Pittard underlined that, "even now, there is still a huge number of patients who are being admitted to critical care with COVID [and] we’re still way above our normal capacity".

This is against a background of a shortage of critical care capacity that preceded the pandemic. A 2018 report from the Faculty of Intensive Care Medicine outlined that 62% of units did not have a full nursing complement and 40% of units had to close beds due to staffing shortages on a weekly basis.

The results were cancelled operations and a negative impact on the quality of care and patient safety.

Nevertheless, the most recent data shows that great strides have been made in improving outcomes of patients admitted to critical care with COVID-19.

Patients admitted to critical care with COVID-19 since 1 May, 2021, have been less likely to require advanced respiratory support, at 42.7% versus 72.1% in the first wave of the pandemic.

They have also spent less time in critical care, down from an average of 14 days at the start of the pandemic to 10 days in the current period, and they are less likely to need renal support, at 12% versus 26.7% in the first wave.

Crucially, overall mortality among COVID-19 patients in critical care has fallen from 39.4% in the first wave to 25.4% among those admitted since 1 May, 2021.

Dr Pittard said that these improvements are thanks largely to the ready availability of continually updated guidance, such as the National Institute for Health and Clinical Care Excellence (NICE) COVID-19 rapid guideline: Managing COVID-19.

RECOVERY

Recommendations include the use of low molecular weight heparin, remdesivir and tocilizumab, along with dexamethasone 6 mg daily for 10 days in patients requiring supplemental oxygen.

This is based on findings from the landmark Randomised Evaluation of COVid-19 thERapY (RECOVERY) trial, which showed that low-dose dexamethasone could save the lives of up to a third of hospitalised patients with severe respiratory complications from COVID-19.

Dr Rama Vancheeswaran, consultant respiratory physician, West Hertfordshire Hospitals NHS Trust, Enfield, said that there was a "beauty" to the RECOVERY trial.

"It was fast, it was pragmatic," she continued, it was "adaptive", it used "us lot, the frontline clinicians, and it got very rapid data".

Dr Vancheeswaran said that her "take home", both from frontline care during the COVID-19 pandemic and trials such as RECOVERY, has been "all about engagement and our buy-in to R&D… and really engaging in quality care".

The key principles have been inclusivity, guidance- and evidence-based medicine, "and using everybody in the front line".

However, she said some lessons from experiences have still not been learned.

"We need to use primary care more, community-based care" more, and to apply the principles of the RECOVERY trial to future studies of, for example, long COVID and post-COVID fibrosis.

She drew attention to trials that are currently underway that have less than 70 patients enrolled across seven or eight hospitals, saying that "this is not what RECOVERY taught us", and urged trialists to follow its "landmark" design.

No funding declared.

No relevant financial relationships declared.

Med+ 2021: Session - Clinical COVID-19 update. Presented 26 October.

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