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

  1. Sky Vanderburg
  2. Narges Alipanah
  3. Rebecca Crowder
  4. Christina Yoon
  5. Richard Wang
  6. Neeta Thakur
  7. Kristin Slown
  8. Priya B. Shete
  9. Martin Rofael
  10. John Z. Metcalfe
  11. Cindy Merrifield
  12. Carina Marquez
  13. Katherine Malcolm
  14. Michael Lipnick
  15. Vivek Jain
  16. Antonio Gomez
  17. Gregory Burns
  18. Lillian B. Brown
  19. Christopher Berger
  20. Vincent Auyeung
  21. Adithya Cattamanchi
  22. Carolyn M. Hendrickson

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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 cmH 2 O 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.

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  1. ScreenIT

    SciScore for 10.1101/2020.05.27.20114090: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: The UCSF Committee on Human Research approved the study and waived the requirement for informed consent (researchers analyzed only de-identified, anonymized data).
    Consent: The UCSF Committee on Human Research approved the study and waived the requirement for informed consent (researchers analyzed only de-identified, anonymized data).
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Data from the electronic medical record were extracted using a form in Research Electronic Data Capture software (REDCap).
    REDCap
    suggested: (REDCap, RRID:SCR_003445)
    Analysis was performed with Stata 15.1 software (StataCorp).
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has several limitations. First, this is a small cohort of patients from a single center with censoring of outcome data for 8 patients who remain intubated without adjudication of ultimate disposition. Mortality may be underestimated but would still be at most 40% in ventilated patients, similar to what has been reported for moderate to severe ARDS.31 Second, our COVID-19 ICU staffing model and resource mobilization was possible due to monetary support from emergency funds and may not be generalizable in particular to private or non-academically affiliated healthcare systems. Last, our study was not designed to evaluate reasons for the high proportion of Latinx patients in our cohort (77%) compared to the usual patients who receive care in our hospital (25%), an important disparity that requires further study. Our early experience of the COVID-19 pandemic substantively adds to what is known about outcomes in critically ill patients with COVID-19 pneumonia and does not resemble the experience reported in many other settings. Majority of patients (81%) have been discharged from the ICU, including 65% who have been discharged home. Early efforts to develop coordinated local and regional response plans with contingency planning for personnel, equipment, and pharmaceutical shortages are vital to prepare for later phases of this pandemic with anticipated ebbs and flows in patient volume. While awaiting the results of clinical trials and ultimately an effective vaccine, our...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2020.05.27.20114090 on medRxiv