Always Room for Improvement
Monday 8th June 2020
Figures for 7th June
UK COVID Deaths 77 / Total 40,542
James Cook Hospital – Total COVID deaths – 241
I am enjoying one last day of holiday before I’m back at work tomorrow. I thought I’d share the latest report from the Intensive Care National Audit & Research Centre (ICNARC). They report data on COVID patients that have been admitted to Critical Care Units throughout the UK. This report includes all UK admissions up until 4th June. It is the most comprehensive report to date and effectively deals with nearly all the cases seen during the initial ‘surge’.
This report deals with 12,375 patients admitted to Critical Care Units with confirmed COVID-19. Of these, they have complete data on 9623 patients. The outcome of 8533 patients is known and the other 1055 remain within ICU, still being treated.
London and the south and east of the country have still seen the most Critical Care admissions. Birmingham and the Black Country are next, with Greater Manchester, Cheshire & Merseyside and the North of England Network (the area north of Leeds) having treated similar numbers of patients.
The report continues to show that the median age of those admitted is 60 years and that 71% of these patients are men.
74% of people admitted were overweight (62% of the general population is normally overweight). 9.4% of all patients admitted to Critical Care had what can be described as a ‘very severe’ underlying illness. 61% of patients needed intubation and ventilation within the first 24 hours of arrival in Critical Care. This number has fallen and probably represents increasing numbers of patients who were given CPAP in order to avoid ventilation as their illness severity scores have not changed since the last few reports.
A new feature in this report is a detailed look at patient demographics adjusted for ethnicity. Comparing White and BAME patients, the BAME patients are younger (median age 57 vs 61) and more likely to come from a deprived area – 31% of BAME patients fall into the most deprived group, compared with 22% of white patients. 69% of the BAME patients were overweight, compared with 76% of the white patients.
7.7% of the BAME patients had a ‘very severe’ underlying illness compared with 10.6% of the white patient population. Of interest is that 57% of white patients needed intubation and ventilation within the first 24 hours of arrival in Critical Care, compared with 68.5% of BAME patients. This is despite oxygen requirements and illness severity scores being very similar.
What is good news is that Critical Care mortality rates have improved over the past month. Of the 8533 patients whose outcome is known, 42% have died and 58% have survived to leave ICU alive. The survivors have been treated for an average of 11 days. Of these 8533 patients who were admitted to Critical Care Units, 72% of them required a ventilator and 25% have required dialysis for kidney failure.
This improvement in survival will be partly explained by the fact that early outcome figures did not take into account a significant number of people who remained on a ventilator in ICU for a number of weeks; people like my friend Gary. Thankfully, like Gary, a number of these patients will have survived, leading to an improved overall outcome. Hopefully it also represents the growing experience of ICU staff in dealing with the sickest COVID-19 patients.
Overall, 55% of men and 63% of women have survived. Breaking down survival by age, 84% of under 40’s have survived to leave ICU, 77% of those in their 40’s, 64% of those in their 50’s, 50% of those in their 60’s and 38% of those in their 70’s and 80’s.
Looking at survival by degree of organ failure, figures have again improved. 80% of all patients receiving CPAP in Critical Care survived whilst 49% of all ventilated patients survived. There has been a big improvement in the survival of patients in kidney failure with 37% of patients who need dialysis surviving.
Of course, some of this may be that ICU teams are better now at recognising which patients with multiple organ failure will not benefit from prolonged, futile attempts at treatment but most of the improvement will be the fact that the sicker patients with kidney failure took longer to survive and recover and were not included in previous figures.
Taking another look at the BAME population, the overall mortality of BAME patients was 55% whilst 59% of white patients survived. There is evidence that the BAME patients were sicker, with significantly more of them requiring intubation and ventilation and dialysis. This is in keeping with national studies and statistical analysis highlighting the increased risk of death in this group.
This report is an important one. It highlights what ICUs across the country have achieved during this peak surge of cases. We are all relived to see that mortality is improving because there have been times when we have all felt powerless to influence our patients outcomes.