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January 20, 2021

Outcomes improving for critically ill COVID-19 patients, Penn study finds

Clinical efforts at hospitals drove better results even before emergence of evidence-based treatments

Mortality rates for critically ill COVID-19 patients have progressively improved over the course of the coronavirus pandemic, even during the period before evidence-based treatments became standard, according to researchers at the University of Pennsylvania.

A study published this week in the Annals of Internal Medicine attributes the trend of improvement to adjustments made by clinicians and hospital staff to better manage the novel disease.

Researchers examined data from 21 intensive care units across five Penn Medicine hospitals, focusing on outcomes of patients with COVID-19 admitted over 15-day increments. The period of the study ranged from March, when the pandemic hit the United States, through July.

Mortality over a 28-day period declined with each consecutive period. And while in-hospital COVID-19 mortality in ICUs was as high as 43.5% during the earliest period, that figure dropped to 19.2% during the final 15-day period, despite many of these patients showing the same disease characteristics and severity.

Despite these improvements, the toll of the coronavirus pandemic is immense. More than 400,000 U.S. residents have died of COVID-19, including 100,000 in the last five weeks

"These findings make us proud after a difficult year," said co-lead author Dr. George L. Anesi, who co-chairs the Penn Medicine Critical Care Alliance COVID-19 and Pandemic Preparedness Committee. "COVID-19 remains a dangerous and deadly disease, but data suggests that our clinicians and front-line workers have quickly gained wisdom and practical knowledge from all of the experience and used that to help more critically ill patients survive."

Much of the success at Penn Medicine was attributed to the information sharing that took place through the Critical Care Alliance COVID-19 Task Force, which released 15 clinical practice guidelines for COVID-19 patients over a 10-week period. The recommendations included surge location and staffing templates, equipment surveillance dashboards for ventilators and an online curriculum to train non-ICU physicians who were redeployed to surge locations.

"Our Critical Care Alliance immediately rose to the challenges of the pandemic, and through an iterative approach, our practice continues to evolve based on the evidence," said co-lead author Juliane Jablonski, a critical care systems strategist.

Since the early months of the pandemic, several medications have emerged as valuable tools in treating patients who are critically ill with COVID-19, including the corticosteroid dexamethasone, the antiviral remdesivir, the rheumatoid arthritis drug baricitinib, convalescent plasma, and blood thinners.

Other emerging treatments, such as monoclonal antibodies, represent hope for further improvement if they can be made more widely available to administer to patients early in the course of the disease, when they would be most effective.

But the key to the Penn study is that significant improvement in patient outcomes can be won through highly coordinated planning and training at hospitals.

"Separate from the evidence-based medications we now have, we cannot yet say what specifically has made a difference, but it's likely a combination of many adjustments and additions along with a commitment to constant reflection and the principles of critical care," Anesi said.

As a follow-up to the existing study, the Penn team will look to analyze more closely which efforts have made the most significant impact.

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