Acuity level of care as a predictor of case fatality and prolonged hospital stay in patients with COVID-19: a hospital-based observational follow-up study from Pakistan

Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan

Background

Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality.

Methods

A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses.

Results

Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]).

Conclusions

Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.

Predictors of prolonged hospitalization of COVID-19 patients

PURPOSE

Despite the importance of hospital bed network during the pandemic, there are scarce data available regarding factors predictive of prolonged length of hospitalization of COVID-19 patients.

METHODS

We retrospectively analyzed a total of 5959 consecutive hospitalized COVID-19 patients in period 3/2020-6/2021 from a single tertiary-level institution. Prolonged hospitalization was defined as hospital stay > 21 days to account for mandatory isolation period in immunocompromised patients.

RESULTS

Median length of hospital stay was 10 days. A total of 799 (13.4%) patients required prolonged hospitalization. Factors that remained independently associated with prolonged hospitalization in multivariate analysis were severe or critical COVID-19 and worse functional status at the time of hospital admission, referral from other institutions, acute neurological, acute surgical and social indications for admission vs admission indication of COVID-19 pneumonia, obesity, chronic liver disease, hematological malignancy, transplanted organ, occurrence of venous thromboembolism, occurrence of bacterial sepsis and occurrence of Clostridioides difficile infection during hospitalization. Patients requiring prolonged hospitalization experienced higher post-hospital discharge mortality (HR = 2.87, P < 0.001).

CONCLUSIONS

Not only severity of COVID-19 clinical presentation but also worse functional status, referral from other hospitals, certain indications for admission, certain chronic comorbidities, and complications that arise during hospital stay independently reflect on the need of prolonged hospitalization. Development of specific measures aimed at improvement of functional status and prevention of complications might reduce the length of hospitalization.

Hospital length of stay for COVID-19 patients: A systematic review and meta-analysis

The length of stay in the hospital for COVID-19 can aid in understanding the disease's prognosis. Thus, the goal of this study was to collectively estimate the hospital length of stay (LoS) in COVID-19 hospitalized individuals. To locate related studies, international databases (including Google Scholar, Science Direct, PubMed, and Scopus) were searched. The I² index, the Cochran Q test, and T² were used to analyze study heterogeneity. The mean LoS in COVID- 19 hospitalized patients was estimated using a random-effects model. COVID-19's total pooled estimated hospital LoS was 15.35, 95%CI:13.47-17.23; p<0.001, I² = 80.0). South America had the highest pooled estimated hospital LoS of COVID-19 among the continents, at 20.85 (95%CI: 14.80-26.91; p<0.001, I² = 0.01), whereas Africa had the lowest at 8.56 8 (95%CI: 1.00-22.76). The >60 age group had the highest pooled estimated COVID-19 hospital LoS of 16.60 (95%CI: 12.94-20.25; p<0.001, I² = 82.6), while the 40 age group had the lowest hospital LoS of 10.15 (95% CI: 4.90-15.39, p<0.001, I² = 22.1). The metanalysis revealed that COVID-19's hospital LoS was more than 10 days. However, it appears that this duration varies depending on a number of factors, including the patient's age and the availability of resources.

Time to recovery from Covid-19 and its associated factors among patients hospitalized to the treatment center in South Central Ethiopia

Coronavirus outbreak was a public health emergency. The surge of new confirmed cases and deaths was observed in developing countries due to the occurrence of new variants. However, factors associated with the duration of recovery among admitted patients remained uncertain. Therefore, we assessed factors associated with time to recovery from Covid-19 among hospitalized patients at the treatment center in South Central, Ethiopia. We employed a retrospective cross-sectional study among 422 patients hospitalized at Bokoji Hospital treatment center with Covid-19 from July 1, 2020, through October 30, 2021. Data were entered, coded, and analyzed using SPSS 26 version. We computed the survival probability using the Kaplan Meier method and determined factors associated with time to recovery using Cox regression analysis. Finally, the interpretation of adjusted hazard ratio (AHR) with 95% Confidence Interval (CI) and P-values less than 0.05 were declared as statistically significant. Our study found that the median time to recovery from Covid-19 infection of 13 days, with an IQR of 9-17 days. In multivariate Cox regression, ≥ 60 years old (AHR = 0.66; 95% CI: 0.49, 0.895), chronic pulmonary disease (AHR = 0.67; 95% CI: 0.455, 0.978), Male (AHR = 0.77; 95% CI: 0.611, 0.979), and being on Intranasal oxygen care (AHR = 0.56; 95% CI: 0.427-0.717) were significantly associated with time to recovery. Thus, health providers in treatment centers should give strict follow-up and priority for elders, patients with underlying diseases, and under supportive treatment during case management.

Tocilizumab in critically ill COVID-19 patients: An observational study

Tocilizumab decreases inflammatory response in the cytokine storm which is one of the mechanisms behind the development of ARDS in COVID-19 patients. The objective of our study was to determine response of tocilizumab in patients suffering from COVID-19 by analyzing clinical parameters and inflammatory markers. A single-arm observational retrospective study was conducted from March 15, 2020 to March 15, 2021. Clinical outcomes in terms of mortality, weaning from mechanical ventilator, improvement in laboratory parameters including inflammatory cytokines, and length of hospital stay were documented. Reduction in values of inflammatory markers, and patients discharged home in stable condition were defined as an improvement after tocilizumab administration. A total of 514 patients received tocilizumab, majority of whom were critically sick 333 (64.8%). Out of the total sample 363 (70.6%) patients were discharged home in stable condition. Overall mean length of stay was 11.50 ± 8.4 days. There was significant difference in length of stay of patients who required invasive mechanical ventilation as compared to those who were kept only on supplemental oxygen (p < 0.05). Patients who were discharged home showed significant improvement in inflammatory markers and neutrophil to lymphocyte ratio as compared to those who expired (p < 0.05). A total of 21 (4.1%) patients had positive blood culture while 57 (11.1%) had positive culture of tracheal aspirate. Hence, tocilizumab is found to be a reasonable therapeutic option for worsening COVID-19 pneumonia by decreasing the need for mechanical ventilation. However, it is associated with adverse events including bacterial and fungal infections.