Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.
Health Data Department, Hospices Civils de Lyon, Lyon, France.
Intensive Care Med. 2023 Mar;49(3):313-323. doi: 10.1007/s00134-023-07000-3. Epub 2023 Feb 25.
The mobilization of most available hospital resources to manage coronavirus disease 2019 (COVID-19) may have affected the safety of care for non-COVID-19 surgical patients due to restricted access to intensive or intermediate care units (ICU/IMCUs). We estimated excess surgical mortality potentially attributable to ICU/IMCUs overwhelmed by COVID-19, and any hospital learning effects between two successive pandemic waves.
This nationwide observational study included all patients without COVID-19 who underwent surgery in France from 01/01/2019 to 31/12/2020. We determined pandemic exposure of each operated patient based on the daily proportion of COVID-19 patients among all patients treated within the ICU/IMCU beds of the same hospital during his/her stay. Multilevel models, with an embedded triple-difference analysis, estimated standardized in-hospital mortality and compared mortality between years, pandemic exposure groups, and semesters, distinguishing deaths inside or outside the ICU/IMCUs.
Of 1,870,515 non-COVID-19 patients admitted for surgery in 655 hospitals, 2% died. Compared to 2019, standardized mortality increased by 1% (95% CI 0.6-1.4%) and 0.4% (0-1%) during the first and second semesters of 2020, among patients operated in hospitals highly exposed to pandemic. Compared to the low-or-no exposure group, this corresponded to a higher risk of death during the first semester (adjusted ratio of odds-ratios 1.56, 95% CI 1.34-1.81) both inside (1.27, 1.02-1.58) and outside the ICU/IMCU (1.98, 1.57-2.5), with a significant learning effect during the second semester compared to the first (0.76, 0.58-0.99).
Significant excess mortality essentially occurred outside of the ICU/IMCU, suggesting that access of surgical patients to critical care was limited.
为应对 2019 年冠状病毒病（COVID-19），大多数医院资源被动员起来，这可能会影响非 COVID-19 外科患者的护理安全，因为他们难以获得重症或中级护理病房（ICU/IMCU）的治疗。我们估计 ICU/IMCU 因 COVID-19 患者过多而不堪重负，导致手术死亡率过高，以及两次大流行浪潮之间的任何医院学习效果。
本项全国性观察性研究纳入了 2019 年 1 月 1 日至 2020 年 12 月 31 日期间在法国接受手术且无 COVID-19 的所有患者。我们根据患者在 ICU/IMCU 病房住院期间，同一医院内所有接受治疗的患者中 COVID-19 患者的每日比例，确定每个手术患者的大流行暴露情况。使用多层模型，并嵌入三重差异分析，估计标准化住院死亡率，并比较不同年份、大流行暴露组和学期的死亡率，同时区分 ICU/IMCU 内和 ICU/IMCU 外的死亡情况。
在 655 家医院接受手术的 1870515 例非 COVID-19 患者中，有 2%死亡。与 2019 年相比，2020 年第一和第二学期标准化死亡率分别增加了 1%（95%CI 0.6-1.4%）和 0.4%（0-1%），这在 ICU/IMCU 暴露程度较高的医院中更为明显。与低暴露或无暴露组相比，这意味着在第一学期，ICU/IMCU 内外的死亡风险均更高（调整后的优势比 1.56，95%CI 1.34-1.81），其中 ICU/IMCU 内（1.27，1.02-1.58）和 ICU/IMCU 外（1.98，1.57-2.5）。在第二学期，与第一学期相比，风险显著降低（0.76，0.58-0.99），表明外科患者获得重症监护的机会有限。
显著的超额死亡率主要发生在 ICU/IMCU 之外，表明外科患者获得重症监护的机会有限。
