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  • Writer's pictureRichard Cree

Measuring Up

Updated: Jul 2, 2020

Wednesday 1st July 2020

Figures for 30th June

UK COVID Deaths 155 / Total 43,750

James Cook Hospital – Total COVID deaths – 254

We have not seen an increase in COVID-19 admissions at the hospital. We have also not had any COVID-related deaths for a few days, which is a relief. Most of us believe that it is inevitable that we will see cases start to rise at some point but the events unfolding in Leicester cause us to wonder whether this will be sooner than we’d like.

We are trying to make the most of the current lull in cases in order to look back and reflect on what we did well and what could have gone better. In this regard we have been helped by the publication of an ICNARC report that specifically deals with the Critical Care patients cared for at the James Cook Hospital.

The Intensive Care National Audit & Research Centre (ICNARC) provides data on patients that have been admitted to Critical Care Units throughout the UK. This report deals with the 104 COVID patients we admitted up until late June. We have complete information on 100 of these, with outcome data on 98 of them. Two patients were still receiving ICU treatment when the report was compiled.

Comparing our patients to those around the country, our patients were of a similar age, with a median figure of 61 years. 35% of our patients were women which is higher than the national figure of 29%.

Ethnically, 92% of our patients were white and 5% were Asian. We admitted no patients of mixed or black ethnic origin. Nationally, 67% of patients were white, 15% were Asian, 2% were of mixed origin and 10% were black.

We already knew that our patients were more likely to come from deprived areas but we were surprised by just how many came from the most deprived group. The Index of Multiple Deprivation (IMD) scale uses five categories, with category 1 being the least deprived and category 5 being the most deprived. 47% of our patients came from category 5, the most deprived category. The national figure is 25%. The remainder of the patients were spread evenly between the other four categories.

We also suspected that we were seeing more obese patients become seriously unwell with COVID-19 and the ICNARC data supports this. We had marginally fewer overweight and obese patients when compared to the rest of the country but 15% of our patients were categorised as severely obese, compared to 8% nationally.

The incidence of severe health problems and dependency due to health reasons were similar to the rest of the country.

Of great interest is the fact that we intubated and ventilated 29% of our patients within the first 24 hours. The national figure is 61%. These patients had an almost identical severity of illness score when compared with the national figure but our patients needed less oxygen on admission to ICU.

Looking at mortality, 37.8% of our patients died. Nationally the figure is 41.1%. We intubated fewer patients than other units, with 52% of our patients requiring ventilation. Whilst our overall mortality figure is better than the national average, the figure for our intubated patients is worse, with 62% of our intubated patients dying, compared with 50% nationally.

The higher mortality in the ventilated patients seems worrying initially but looking into this in more detail, it appears one sub-group of ventilated patients is responsible for the higher death rate. Our patients who only had respiratory failure and were ventilated had the same survival rate as the rest of the country. Our ventilated patients with heart failure or kidney failure requiring dialysis did significantly better than rest of the country. It was our patients with respiratory failure, heart failure AND kidney failure that did worse than similar patients elsewhere. These were, by far, our sickest patients and we saw relatively few of these.

So what can we make of these figures?

The lower overall mortality rate at our hospital means that, on average 3% less patients have died in our critical care unit compared with other hospitals. Of course, our numbers are relatively low and so there is a higher potential for error when analysing the data. This may be especially true for our sickest patients. Our patients are fatter, more deprived but more likely to be of white ethnicity. Do these risk factors balance each other out?

The really interesting discovery is that we have intubated and ventilated significantly fewer patients than other units, with many more patients receiving ‘basic respiratory support’. This involves using high-flow oxygen delivery systems or CPAP. Does this mean that using CPAP rather than ventilation is protective in COVID pneumonitis? Or should we be intubating patients earlier if CPAP is not working as we have seen a higher mortality in some of our intubated patients? We are collecting more data from our CPAP patients to be able to answer this. We need information such as the severity of respiratory failure in the CPAP patients, overall illness severity, the incidence of underlying health conditions and how many days they received CPAP. Without this we may be inadvertently comparing apples and pears.

We also managed dozens of CPAP patients on the ward using our Outreach nurses to support the ward medical teams. These were often less sick than the patients admitted to ICU. Many hospitals disbanded their Outreach teams when the pandemic started in order to staff their expanded ICUs. Had we done the same and ended up admitting these patients to the ICU, I suspect we would have seen significantly more survivors.

We will continue to use CPAP in COVID pneumonitis as all of us believe that it can lower mortality if used correctly and appropriately. We will take some comfort in our lower mortality figures but will fight any temptation to become complacent. We can always do better.

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