Doctors have been warning for months that, although they are better at saving the lives of critically ill Covid-19 patients, these gains will diminish if hospitals are overloaded as in the early days of the pandemic.
With coronavirus deaths now skyrocketing in the United States and several other countries, this prediction may be coming true: the crushing of new patients at Covid-19 hospital is likely to lead to more deaths.
When intensive care units go from zero occupied beds to all occupied beds, patients have a 92% higher risk of death due to Covid-19, according to a preprint published on MedRxiv on Wednesday. (The article must be peer-reviewed.)
This means that when hospitals are pushed to maximum ICU capacity, the worst case scenario is almost twice the risk of death for critically ill patients, the study concluded. For example, a 40-year-old person in a full intensive care unit would have the same risk of death as a 51-year-old, the study authors – researchers from UK institutions, including Imperial College London, University College London and Wellcome Trust – estimated.
These risks decreased along the gradient: as occupancy rates increased, so did the risk of death. A second new prepress, analyzing data from nearly 20,000 Covid-19 patients in Israel, came to a similar conclusion:
The studies are particularly relevant at a time when more than a fifth of hospitals with intensive care units in the U.S. are reporting ICU bed occupancy levels of at least 95 percent and the daily coronavirus death count has reached a historic record (4,320 on January 13). Newspapers are also a bleak reminder of why allowing the virus to spread wildly is so dangerous, even if doctors have better treatments for disease and vaccines are being launched worldwide.
“I’m saying [high] occupation leads to mortality, ”said Bilal Mateen, author of a UK article and clinical researcher who works at the Wellcome Trust and Kings College Hospital in London. “So, even if the virus isn’t killing you directly, indirect factors – like the level of ICU occupation on the day you arrive at the hospital – are likely to change your risk.”
Healthcare professionals are better at treating Covid-19 – but they need the time and resources to do so
Covid-19 hospitalizations have taken a heavy toll on hospital systems around the world. But with all the terrible news about the pandemic, it’s easy to ignore the incredible progress that doctors have made in understanding and treating the disease.
Just a year ago, the medical community knew nothing about this new disease. The doctors thought they were dealing with viral pneumonia that mainly affected the lungs. “We don’t think of it as a full-body viral attack – and it’s still what we have,” Lewis Kaplan, president of the Society of Critical Care Medicine, told Vox in October. “There is practically no organ system – from the skin to the blood vessels, from the brain to the nose – that is not involved in one way or another.”
There is still a lot to learn about Covid-19, but even this change in understanding came with improved medical care. Healthcare professionals now have numerous evidence-based tools at their disposal to save more lives. For example, there is strong evidence that common steroids such as dexamethasone can reduce the risk of mortality in critically ill patients. There is also strong evidence for monoclonal antibodies, such as tocilizumab and sarilumab, which are commonly used to treat rheumatoid arthritis.
Putting patients to rest on their stomachs instead of on their backs (a practice known as pronation) also seems to help, and certain types of convalescent plasma are promising.
Taken together, these medical advances are why – before the increase in cases in the United States and abroad – ICU doctors told Vox that they generally expect their patients to survive the disease.
But healthcare professionals have also warned that these gains may disappear as the cases start to pile up again – and doctors, respiratory therapists and nurses in hospitals become tense.
“When the hospital is full, everything is interrupted and a kind of ‘soft rationing’ begins,” Lakshman Swamy, who works with the Cambridge Health Alliance, told Vox. “The ICU has to raise the level of how sick you need to be to enter the ICU. If you add a stretched team … you basically end up providing slower and less ideal care for everyone, including the sickest patients. ”And that can increase the risk of death for patients.
Governments need to prevent stress in hospitals
The new studies quantify the point at which deaths begin to increase – and do not require hospitals to reach their maximum capacity.
With British prepress, Mateen and his colleagues used data from the first wave of Covid-19 in the UK, from April to June, to model ICU occupation – specifically, the number of patients in beds with ventilators – at the time that a person was admitted to a hospital. They related the occupation data to the patients’ chances of survival.
There were 4,032 patients with confirmed or suspected Covid-19 during the study period. The researchers adjusted patients’ comorbidities and age to ensure that these factors did not affect survival outcomes.
The study’s main finding: a patient admitted to the hospital when the occupation was greater than 85% had an almost 20% higher risk of death compared to those admitted when the occupation was about 45%. Therefore, even with occupancy rates of 85%, the risk of death for a patient increased.
But going from zero percent ICU occupancy to 100 percent on the day of a patient’s admission was related to an even more dramatic 92 percent risk of death.
“Every day we delay [strong anti-virus measures] in the context of a 90 percent occupation, there are probably people who are dying as a result, ”said Mateen. As of January 7, 79 percent of ICU beds were occupied in the United States, according to the New York Times, with a fifth of hospitals with intensive care units reporting ICU bed occupancy levels of 95 percent or more .
The researchers from the Israeli article – which included all 19,336 Covid-19 patients hospitalized in Israel from mid-July 2020 to early January 2021 – also adjusted for the patient’s age, sex and health status on the first day of hospitalization. They found that even under conditions that the Israeli government considers feasible for adequate patient care – 500 critically ill patients hospitalized across the country – the death rate for patients with Covid-19 begins to rise.
Leora Horwitz, a medical professor at NYU who has been studying the mortality of Covid-19 and was not involved in the new preprint, noted that there may be other explanations for the increased risk of death as hospitals fill up. For example, there may be a potential selection bias that happens in the ICU: if more sick patients are admitted, compared to less stressful days, this would also lead to an increase in mortality.
Still, she said, “hospital pressure probably contributes,” and the implication couldn’t be clearer: governments need to do everything possible to prevent infections now.
“The idea behind flattening the curve was that even if we have to have the same number of infections – if we can spread them over time, we can prevent our hospitals from being [overwhelmed]”Said Horwitz. “Now that we have a vaccine, we can do even better than flatten the curve – we can dramatically reduce the total number of infections,” because people can avoid contracting the disease.
Communities need to reduce infections through social distance and the use of masks, while governments quickly deploy the Covid-19 vaccine.
But around the world, these measures are not happening quickly or effectively enough – as Mateen is seeing firsthand in London. He is expected to return to part-time work helping to treat Covid-19 patients on Friday, but the context is different from his last hospital shifts in the fall. One in 30 people in London now tests positive for the virus – after the arrival of a new highly contagious variant in the UK – and the city’s mayor has just declared a state of emergency, warning that “more people will die” as the hospitals get crowded.
Mateen’s medical friends – who have “borne a huge burden” for months – are anxiously circulating stories about hospitals in the UK having to ration oxygen where supplies are running low.
“There’s an emotional voice in your head saying ‘why the hell are we being forced to have this conversation [about rationing care], ”Mateen said,“ when there is no legitimate reason for having reached this point. ‘”