Between 5th March 7th May 2020, a total of 599 patients tested positive for SARS-CoV-2 in LTHT and of these, 65 were admitted for reasons other than COVID-19, 38 were not hospitalised, five were aged <18 years and six tests were subsequently amended as negative following quality control. The final dataset therefore consisted of 485 patients, with a mean age of 71.2 ± 16.9 years of whom 259 (53·4%) were male. A total of 109 (22·5%), 130 (26·8%), 105 (21·6%) and 141 (29·1%) had zero, one, two and three or more major co-morbidities, respectively. The most common co-morbidity was hypertension, which was present in 222 (45·8%) patients, whilst 147 (30·3%) had diabetes mellitus (Table 1). Self-reported ethnicity was available for 475 patients (97·9%), of whom 402 (84·6%) classified themselves as White-European, 31 (6·5) as South-Asian, 19 (4·0%) as Black-African, two (0·4%) as East-Asian and 21 (4·4%) as either mixed or other ethnicities.
Ceiling of care and cardiopulmonary resuscitation decisions
Following consultation with patients and their next-of-kin, pre-emptive ceiling of care decisions were documented for 409 (84·3%) patients hospitalised with SARS-CoV-2 infection. Of patients in whom these decisions were made, 208 (50·9%), 75 (18·3%) and 126 (30·8%) patients were deemed suitable for a maximum of level one, two or three care, respectively. Bar charts showing ceiling of care decisions divided by patient demographics are displayed in Figure 1. CPR decisions were made for 451 (93·0%) patients, of whom 336 (74·5%) were deemed not for CPR in event of cardiac arrest, whereas 115 (25·5%) were.
Demographics and clinical characteristics
Patients considered suitable for escalation of treatment were younger, less frail and had fewer major co-morbidities. In unadjusted analysis, age was strongly associated with treatment escalation decisions, most evident in patients over 85 years of age (odds ratio (OR) 0·004, 95% confidence interval (CI) 0·001-0.017, p<0·001). Other variables associated with ceiling of care decisions were higher CFS, lower BMI, a diagnosis of any major co-morbidity, the prescription of cardiovascular medications and White-European ethnicity (Figure 2).
Compared to White-European patients, BAME patients were on average younger (58·0 ± 15·4 vs 73·7 ± 16.0 years, p<0·001), had fewer major co-morbidities (1 (0,2) vs 2 (1,3), p=0·037) and were less frail (CFS 2 (2,4) vs 5 (3,7), p<0·001). When adjusted for age and sex White-European ethnicity was not associated with ceiling of care decisions, nor were there associations between ceiling of care decisions and lower BMI or the prescription of most cardiovascular medications. Associations between a ceiling of care decision of less than level three and frailty, a diagnosis of diabetes mellitus, COPD, CKD, history of stroke or TIA and prescription of loop diuretic or statin remained when adjusted for age and sex. In multivariate regression analysis, predictors of ceiling of care decisions were advanced age (OR 1·1 per year, 95% CI 1·1-1·2, p<0·001) and higher CFS (OR 2·1, 95% CI 1·7-2·7, p<0·001) (Table 2). No other clinical or demographic variables were independently associated with the decision to limit the maximal care level provided. No individual co-morbidities featured as part of a multivariable analysis although there was a significant association between the cumulative number of major co-morbidities and ceiling of care decisions (OR 1·4 per co-morbidity, 95% CI 1·0-1·9, p=0·048) (Table 3).
Clinical markers of disease severity
Patients deemed inappropriate for level three care had on average fewer markers of severe SARS-CoV-2 infection at the time of presentation compared to those who were (Table 4). Laboratory markers of systemic inflammation such as C-reactive protein and serum ferritin were more often abnormal in patients deemed eligible for escalation to level three care, as were assessments of physiology such as respiratory rate, heart rate and tympanic temperature. hest radiography data were available for 471 (97·1%) patients at the time of hospitalisation of which 217 (44·7%) were reported as consistent with, 151 (31·1%) were indeterminate for and 103 (21·2%) inconsistent with COVID-19. Patients who were considered appropriate for level three care were more likely to have chest radiography consistent with COVID-19 compared to those who were not (p<0·001), suggesting a higher severity of disease in these patients.
Treatments administered during hospitalisation
During hospitalisation, a total of 383 (79·0%) patients required oxygen therapy, 88 (18·1%) received CPAP, 38 (7·8%) received mechanical ventilation, renal replacement therapy was used in 11 (2·3%) and 28 (5·8%) patients required inotropes or vasopressors. CPAP was delivered in a ward setting for 6 (6.8%), on the high-dependency unit for 13 (14·8%) and on ICU for 69 (78·4%). All patients who required mechanical ventilation were cared for in an ICU setting. Overall, 92 (19·0%) of patients were admitted to ICU, 61 (81·3%) of whom were deemed suitable for level three care, whilst 14 (18·7%) were suitable for, and received, level two care.
The mean length of hospital admission for patients who had been discharged was 12·7 ± 10·5 days and was 25 ± 11·2 days those who remained in hospital. Following a mean follow-up of 12·6 ± 11·2 days, a total of 307 (63·3%) patients had been discharged, 159 (32·8%) had died and 19 (3·9%) remained in hospital. Despite on average having more markers of disease severity, patients deemed to be suitable for level three care were more likely to be discharged and less likely to have died during hospitalisation (p<0·001) (Figure 3). Of the 20 (16%) patients eligible for level three care who died during the study period, all were admitted to ICU and received mechanical ventilation prior to death. Overall, including patients in whom ceiling of care decisions were not documented, 38 (7·8%) received mechanical ventilation during the study period and of these seven (18·4%) had been discharged, nine (23·7%) remained in hospital and 22 (57·9%) had died.
Death during admission was associated with advanced age, White-European ethnicity, higher CFS, a diagnosis of HFrEF, atrial fibrillation, CKD or COPD and the prescription of anticoagulant (Table 5). When adjusted for age and sex, associations between death during admission and higher CFS remained (OR 1·2, 95% CI 1·1-1·4, p=0·001), but not the associations with White-European ethnicity, any major co-morbidity or medication. In a multivariate model including age, CFS and maximum level of care receiving during admission, receipt of level two (OR 2·6, 95% CI 1·1-11·6, p=0·033) or level three care (OR 8·1, 95% CI 3·7-17·8, p<0·001) were associated with an increased risk of death during hospitalisation.