SCCM Resource Library-Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome due to Coronavirus 2019

Video Transcription

Hi there, my name is Chelsea Johnson and I'm a pulmonary and critical care medicine fellow at the Boston University Medical Center.  On behalf of the Virus Discovery Core Research Group, today I'm going to present our findings  from our work entitled Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome Due to Coronavirus 2019.  So to start, volume and pressure limited ventilation and prone positioning for patients with severe ARDS are guideline recommended treatments for ARDS.  Additionally, use of guideline recommended ARDS management strategies for patients with COVID-19 ARDS is unclear.  Therefore, we hypothesize that use of guideline-based ARDS management strategies for COVID-19 ARDS  would vary across hospitals over the first year of the pandemic, and that better adherence to guideline-recommended strategies would be associated with improved COVID-19 ARDS  mortality. For this work, we used the Society for Critical Care Medicine Discovery of Viral Infection  and Respiratory Illness, also known as Virus COVID-19 Registry, with data from February of 2020 through April of 2021.  We looked at hospital risk-adjusted rates of use of guideline-based care determined using multilevel random effects modeling with hospitals as random intercepts and covariates  as fixed effects. And our primary outcomes were the intraclass correlation coefficient and median odds ratio  for hospital use of guideline-based care, which determined variation in use of these practices across hospitals.  And then as an exploratory analysis, we looked at inpatient hospital-level mortality. For the covariates of our models, we looked at both patient and hospital-level variables.  Patient-level variables included demographics, comorbidities, and illness severity as defined  by SOPA score and P-to-F ratio, and hospital-level variables included geographic location, nurse-to-patient staffing ratios, ICU capacity, and academic affiliation.  To further explain our primary outcomes, the intraclass correlation coefficient summarizes the variation in guideline-based ARDS management attributable to the hospital itself.  And then when considering an individual receiving care at a randomly selected hospital with higher versus lower use of guideline-based care, the median odds ratio represents the  median increase in the odds of receiving guideline-based ARDS care at that randomly selected higher use hospital.  So here you see the descriptive characteristics of our cohort of nearly 1,500 adults with COVID-19 ARDS.  We defined ARDS by receipt of mechanical ventilation and a PaO2 to FiO2 ratio less than 300 on a PEEP of at least five.  And these characteristics describe patients receiving care across 42 separate hospitals. On your left, you'll see a sampling of the patient characteristics, and on your right,  a sampling of the hospital characteristics. The median age of our patient population was 64. It was a predominantly male population of 67% male.  Less than a half of patients were white and nearly 20% were black. And the majority of patients had severe ARDS on admission as defined by a P to F ratio less than 100.  Moving on to the hospital characteristics, you'll see that the majority of patients were treated in the United States.  The majority of patients received care in a medical or COVID ICU as compared to a pediatric or mixed medical surgical ICU.  The majority of patients received care at hospitals that were over capacity, which was defined by the number of COVID-19 patients at any given time outnumbering the number  of ICU beds available at that hospital. The majority of hospitals were academic in that they were defined by hospitals where  residents or medical students had first contact with patients when they arrived to the ICU.  And then lastly, a minority of hospitals were characterized by low nurse to patient staffing ratios defined by greater than two patients per nurse.  Moving on to our primary results, here we represent, we present variation in use of guideline-based care across hospitals.  This is a complete case analysis of patients where all guideline-based care covariates were available. These are results from 739 patients across 31 hospitals.  And you'll see that the median rate of guideline-based care for ARDS varied between hospitals with a median hospital level rate of about 50% here and a range from 29% up to 71%.  Hospital of admission contributed 14% of the risk-adjusted variation guideline-based care as defined by the intra-class correlation coefficient.  And the median increase in the odds of a patient receiving guideline-based ARDS care when treated  at a randomly selected hospital with practice patterns highly consistent with guidelines as compared to a hospital with practice patterns less consistent with guidelines was two as  described by the median odds ratio. So looking at the data another way, here you see ARDS management strategies stratified  by hospital quartiles of use of guideline-based care with p-values representing trends of use across quartiles.  And here we see that overall use of guideline-based care, again, as defined by receipt of low tidal volume ventilation, plateau pressure targets less than 30, and prone positioning  for severe ARDS was 50% overall. For those treated in quartile one, use of guideline-based care was as low as 14% and  up to 70% in the quartile of hospitals with the highest use of guideline-based care. Our data demonstrate encouraging signs of relatively high use of each guideline-based  care management strategy alone. However, there's room for improvement in the combined use of these strategies.  We additionally see that rates of prone ventilation for severe ARDS at 62% is double previously  reported rates among patients without COVID-19, which has been reported as low as 16 to 30%.  Interestingly, we also see that use of adjunctive therapies for ARDS management, including paralytics  and inhaled pulmonary vasodilators were used nearly as commonly as evidence-based practices  without predilection for use at low-performing or high-performing guideline-based care hospitals,  warranting further guidance of efficacy and appropriate use specifically within the COVID-19 ARDS population.  Next, looking at our patients stratified by severity of ARDS, we see that while rates of use of low tidal volume ventilation and plateau pressure targets less than 30 were  high at 78% and 74% respectively, one-third of patients with mild ARDS did not receive low tidal volume ventilation, and plateau pressure targets less than 30 were less likely  to be achieved among patients with severe ARDS, as you can see by the arrow across the tertiles.  When looking at factors significantly associated with use of guideline-based care, we see that those with moderate ARDS were more likely to receive care consistent with guidelines,  whereas those with severe disease were less likely. Additionally, female sex and those receiving care in a medical or COVID-specific ICU were  less likely to receive guideline-based care. The discordance in adherence to overall guideline-based care among those with moderate ARDS but not  severe disease seen in our study draws specific attention to patients with severe disease where adherence to plateau pressure targets may be particularly difficult due to poor  lung compliance. Now moving on to the results from our exploratory analysis, first we looked at crude mortality  across hospital quartiles of guideline-based care use, and here you'll see that mortality was lower at the highest-use hospitals at 49% as compared to the lowest-use hospitals  at 60%. In an adjusted analysis of factors associated with mortality, you'll see that receipt of  guideline-based care was associated with a non-significantly lower odds of mortality, whereas for international hospital location and illness severity were significantly associated  with higher mortality, whereas female sex was associated with lower mortality. Our study had several limitations that are important to note.  First, data used in this study was collected from the day of hospital admission or the date first available if hospital data was missing, therefore daily data for each strategy  was not available. Frequency of use of guideline-based care during a given hospitalization is not known.  Furthermore, residual confounding from unmeasured severity of illness cannot be ruled out. And finally, categorization of the continuous guideline-based care variable in quartiles  may have resulted in loss of information, however, spline models had convergence difficulties.  So in summary, this multi-center international study demonstrated that only half of patients  with ARDS due to COVID-19 received care consistent with ARDS guidelines over the first year of the pandemic.  Combined use of low tidal volume ventilation, plateau pressure targets, and prone ventilation for severe ARDS was particularly poor, and patients treated at hospitals with higher  rates of use of guideline-based care had a non-significantly lower odds of mortality. Strategies to align ARDS management with guideline recommendations are needed.  I'd like to acknowledge Dr. Walking and Dr. Garcia, who were integral to the design and analyses for this study, as well as Emily Sisson, who did the analysis for this project,  and of course the core investigator group for the virus registry. And now I'm happy to take any questions, and thank you for your time.

Video Summary

The study presented by Chelsea Johnson focused on the variation in management and outcomes of Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19 across different hospitals. The researchers examined the use of guideline-based treatments and strategies for COVID-19 ARDS and its association with mortality. The study analyzed data from over 1,500 adults across 42 hospitals. The results showed that only 50% of patients received guideline-based care, with significant variation across hospitals. The study also found that higher adherence to guideline-based care was associated with a non-significantly lower mortality rate. The findings suggest a need for strategies to improve the alignment of ARDS management with guidelines.

Asset Subtitle

Pulmonary, Infection, 2022

Asset Caption

INTRODUCTION: Adherence to guideline-recommended ventilator management for acute respiratory distress syndrome (ARDS) due to COVID-19 is unknown. We sought to evaluate variation in use of ‘guideline-based care’ and adjunctive strategies for COVID-19 ARDS across 55 hospitals contributing to the Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry. We hypothesized that COVID-19 ARDS management would vary across hospitals and that hospital-level mortality would be higher at hospitals with lower use of guideline-recommended care as compared to those with higher use. METHODS: In this retrospective, observational study we used multivariable adjusted hierarchical random effects logistic regression to assess hospital-level, risk-adjusted use of ‘guideline-based care’ for ARDS, defined as low tidal volume (low Vt), plateau pressure (Pplat) < 30 cmH2O, and prone position for PaO2:FiO2 ratio (P:F) < 100. RESULTS: Among 2,021 patients with COVID-19 ARDS, 50% received care consistent with ARDS guidelines. After adjusting for demographic, geographic, time, and severity of illness characteristics, hospital of admission contributed to 20% of the risk-adjusted variation in 'guideline-based care’; a patient treated at a hospital with high utilization of recommended therapies had 2.3 times (95% CI 1.3-4.3) the odds of receiving ‘guideline-based care’ as compared to a patient receiving treatment at a randomly selected hospital with lower utilization of ‘guideline-base care.’ Additionally, there was significant hospital level variation in use of paralytics (MOR 4.0, 95% CI 1.6-10.1) and inhaled pulmonary vasodilators (MOR 3.9, 95% CI 1.5-10.2). Mortality was non-significantly lower at hospitals within the highest-use quartile of ‘guideline-based care’ as compared to the lowest-use quartile (risk-adjusted OR 0.5, 95% CI 0.2-1.1, p=0.06). CONCLUSIONS: Only half of patients studied in the international VIRUS registry received guideline-based ventilation strategies for COVID-19 ARDS, with wide variation across hospitals. Given the significant mortality risk associated with COVID-19 ARDS, there is room for improvement in implementation of guideline-recommended ventilator strategies.

Meta Tag

Content Type Presentation

Knowledge Area Pulmonary

Knowledge Area Infection

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Acute Respiratory Distress Syndrome ARDS

Tag Ventilation

Tag COVID-19

Year 2022

Keywords

Acute Respiratory Distress Syndrome

COVID-19

hospitals

guideline-based treatments

mortality rate

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