Management and Outcomes of Critically-Ill Patients with COVID-19 Pneumonia at a Safety-net Hospital in San Francisco, a Region with Early Public Health Interventions: A Case Series

Abstract

Background: Following early implementation of public health measures, San Francisco has experienced a slow rise and a low peak level of coronavirus disease 2019 (COVID-19) cases and deaths. Methods and Findings: We included all patients with COVID-19 pneumonia admitted to the intensive care unit (ICU) at the safety net hospital for San Francisco through April 8, 2020. Each patient had ≥15 days of follow-up. Among 26 patients, the median age was 54 years (interquartile range, 43 to 62), 65% were men, and 77% were Latinx. Mechanical ventilation was initiated for 11 (42%) patients within 24 hours of ICU admission and 20 patients (77%) overall. The median duration of mechanical ventilation was 13.5 days (interquartile range, 5 to 20). Patients were managed with lung protective ventilation (tidal volume <8 ml/kg of ideal body weight and plateau pressure ≤30 cmH2O on 98% and 78% of ventilator days, respectively). Prone positioning was used for 13 of 20 (65%) ventilated patients for a median of 5 days (interquartile range, 2 to 10). Seventeen (65%) patients were discharged home, 1 (4%) was discharged to nursing home, 3 (12%) were discharged from the ICU, and 2 (8%) remain intubated in the ICU at the time of this report. Three (12%) patients have died. Conclusions: Good outcomes were achieved in critically ill patients with COVID-19 by using standard therapies for acute respiratory distress syndrome (ARDS) such as lung protective ventilation and prone positioning. Ensuring hospitals can deliver sustained high-quality and evidence-based critical care to patients with ARDS should remain a priority.

Prevalence of phenotypes of acute respiratory distress syndrome in critically ill patients with COVID-19: a prospective observational study

“…Overwhelmed ICU capacity might have an effect on outcomes in COVID-19 and lower mortality rates have been reported in ICUs that have operated under more conventional conditions and staffing ratios in patients with COVID-19 with similar APACHE II scores. 18 , 19 The low APACHE II scores are also in keeping with those reported by the Intensive Care National Audit and Research Centre in 9777 patients admitted to the ICU in the National Health Service hospitals in the UK, 20 where the median APACHE II score in patients with COVID-19 was 14 (IQR 11–18) and the mortality rate was greater than 40%. These consistent findings suggest that the APACHE II score might not be valid for prognostication in COVID-19.…”

Country differences in hospitalisation, length of stay, admission to Intensive Care Units, and mortality due to SARS-CoV-2 infection at the end of the first wave in Europe: a rapid review of available literature

“…Six studies made reference to time in hospital prior to ICU transfer, including two small case series [57,83], thus excluded from consideration. A short LOS prior to ICU admission is outlined in the remainder articles; including 0 days in Fan et al [21], 1 day in the UK ICNARC report [24] and Kim et al [104], and 2 days in Vanderburg et al [98].…”

Characteristics, management and survival of ICU patients with coronavirus disease‐19 in Norway, March‐June 2020. A prospective observational study

“…30 As a consequence, the number of critically ill COVID-19 patients has been low and patients, 10,12,15,16 and aligns with reports from other countries and regions with early and effective lockdown-policies or a low disease burden. [17][18][19][20]31 ICU LOS was prolonged, and associated with male gender, severity of respiratory failure at admission and being classified as ARDS.…”

“…Although case-mix may differ, evidence is emerging that mortality in the critically ill may be lower under such circumstances. [17][18][19][20] The first Norwegian to test positive for SARS-CoV-2 was identified 21 February 2020. This patient was probably infected in China.…”