COVID-19: Intensive care deaths fell steeply in 2020

• Between the end of March 2020 and October 2020, the overall mortality rate from COVID-19 in intensive care units worldwide declined from 60% to 36%.
• During this time, doctors learned more about which drugs work and which do not, refined their approaches to oxygen and fluid therapies, and improved their management of blood clotting.
• Declines in mortality rates appear to have leveled off toward the end of this period.
• The analysis was unable to take account of the emergence of new strains or the rollout of vaccines.

More than 2.3 million people have died from COVID-19 since the start of the pandemic.

But the ability of healthcare professionals to save the lives of patients in intensive care with the illness has improved markedly over the past year.

In June 2020, a study revealed that the steroid dexamethasone reduced overall mortality among patients hospitalized with COVID-19 by 17%.

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Other research found that drugs that showed early promise, including hydroxychloroquine, azithromycin, and remdesivir, had no clear benefit for reducing mortality.

In parallel, intensive care doctors have refined oxygen and fluid therapies, while improving their management of the excessive blood coagulation that often characterizes the disease.

Therefore, improvements in care led to a steep decline in mortality rates in the pandemic’s early months. However, towards the end of the year, the rate of this decline appeared to tail off.

This is according to a group of researchers in the United Kingdom. The scientists are from:

• the Royal United Hospitals Bath National Health Service (NHS) Foundation Trust, Bath
• the University of Bristol
• James Cook University Hospital, Middlesbrough

Updated review

A previous review and meta-analysis of observational studies by the group found that COVID-19 mortality in intensive care fell by almost a third between the end of March 2020 and the end of May 2020, from around 60% to 42%.

In the ensuing months, the pandemic spread further into the southern hemisphere.

To update their findings to the end of September 2020, the researchers identified 52 observational studies and registries that reported the outcome for a total of 43,128 patients admitted to the ICU with a COVID‐19 diagnosis.

For the first time, they included reports from the Middle East, South Asia, and Australasia in their analysis.

The new analysis revealed that overall mortality fell further, to 36%, suggesting that improvements in care have continued but at a slower rate.

Reporting their results in the journal Anaesthesia, the authors write:

“After our first meta-analysis last year showed a large drop in [intensive care] mortality from COVID-19 from March to May 2020, this updated analysis shows that any fall in mortality rate between June and October 2020 appears to have flattened or plateaued.”

Two outliers

According to the analysis, the mortality rate for intensive care patients with COVID-19 is 30–40% in most geographical regions. However, the study revealed two outliers.

A single report from Victoria, Australia, suggested a mortality rate of only 11%. In contrast, studies covering four countries in the Middle East — Iran, Kuwait, Yemen, and Israel — reported an average mortality rate of 62%.

The authors note that the Middle East studies included outcomes recorded early in the pandemic, when mortality was higher. By contrast, the Australian report covered patients in intensive care later in the pandemic, when mortality was lower.

Additional factors that may have contributed to this discrepancy include:

• variations in healthcare resources
• criteria for admission to intensive care
• statistical uncertainties associated with low patient numbers

New strains and vaccines

The authors write that since October 2020, at the end of the reporting period for their analysis, several new strains of the virus have emerged that are increasing the pressure on intensive care units in some countries.

Conversely, they say, the successful rollout of vaccines in some regions is likely to reduce the number of patients requiring intensive care in the coming months.

Among the major limitations of the analysis, the team acknowledges they could not include any reports of mortality rates in South America or Africa.

In addition, the researchers point to inconsistencies between reports on issues such as:

• what constitutes intensive care
• the underlying health characteristics of patients
• illness severity
• the nature of treatments

“This means that the included patients’ underlying risk is unknown and outcomes between studies are not directly comparable,” they write. “Standardization of reporting would enable far more valuable comparisons of outcomes between locations and over time.”

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