European Review for Medical and Pharmacological Sciences 2021; 25: 3377-3385 Mortality and critical conditions in COVID-19 patients at private hospitals: weekend effect? J. GONZÁLEZ-GANCEDO1,2, I. MORALES-CANÉ1,3,4, P.M. RODRÍGUEZ-MUÑOZ1,5, P. HIDALGO-LOPEZOSA3,4, M. DEL ROCÍO VALVERDE-LEÓN1,3,4, M.E. FERNÁNDEZ-MARTÍNEZ6, F. FABBIAN1,7, M.A. RODRÍGUEZ-BORREGO1,3,4, P.J. LÓPEZ-SOTO1,3,4 1Department of Nursing, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain 2Department of Nursing, Hospital Clínico Universitario de Valladolid, Valladolid, Spain 3Nursing Area, Universidad de Córdoba, Córdoba, Spain 4Nursing Area, Hospital Universitario Reina Sofía, Córdoba, Spain 5Faculty of Health Sciences, Universidad Pontificia de Salamanca, Salamanca, Spain 6Department of Nursing and Physiotherapy, Universidad de León, León, Spain 7Faculty of Medicine, Pharmacy and Prevention, University of Ferrara, Ferrara, Italy Abstract. – OBJECTIVE: The aim of the study ing care of these patients in order to optimize re- was to find factors associated with the mortality sources in pandemic situations. of admission to the intensive care unit (ICU) in patients with COVID-19. Key Words: MATERIALS AND METHODS: Retrospective COVID-19, D-dimer, Comorbilities, Critical care, In- observational study with a database of 1987 tensive care units. patients with COVID-19 who had attended the emergency department of a private hospital net- work between February 2020 and April 2020 were analyzed. Clinical variables and some lab- Introduction oratory parameters were studied. The Charlson and Elixhauser comorbidity indices were cal- Coronavirus disease 2019 (COVID-19) is a culated. The dependent variables were mortal- new viral infection with highly pathogenic conse- ity and admission to the ICU. A descriptive and quences1. The causative agent of this coronavirus correlational analysis was performed. Logistic disease has been identified as SARS-CoV-21,2. Re- regression models and Kaplan-Meier survival curves were established. searchers and experts mention that the first case RESULTS: Positive correlations were ob- appeared on 8 December 2019. On 31 December served between age, creatinine, and D-dimer 2019, the Wuhan Municipal Health Commission levels, as well as with the scores obtained with (Hubei, China) reported 27 cases of pneumonia the Charlson and Elixhauser indices. Differenc- of unknown aetiology with common exposition es in the levels of these parameters were al- in a market in Wuhan. The genetic sequence of so observed when analyzing variables such as SARS-CoV-2 was shared on 12 January 2020. On mortality, sex or admission to the ICU. Mortali- 11 March 2020, the World Health Organization ty was associated with high creatinine and D-di- 2 mer levels and advanced age. Survival curves (WHO) declared the world pandemic . indicated longer survival in patients not admit- Coronaviruses are a group of zoonotic RNA ted to the ICU, admitted to the hospital during viruses causing a large range of symptoms, from the week, and in those with lower creatinine and the mild common cold symptoms to extreme D-dimer levels. respiratory or even neurological, hepatic or en- CONCLUSIONS: Mortality in Spanish patients teric symptoms1. In the case of people infected with COVID-19 admitted to private hospitals was with SARS-CoV-2, they could experience mild to associated with high creatinine and D-dimer lev- els and advanced age. Longer survival was ob- moderate respiratory symptoms, recovering with- tained on weekdays. This study provides valu- out special or intensive treatment. However, there able information on the management and nurs- are high-risk cases, such as elderly people and Corresponding Author: Ignacio Morales Cané, Ph.D; e-mail: [email protected] 3377 J. González-Gancedo, I. Morales-Cané, P.M. Rodríguez-Muñoz, P. Hidalgo-Lopezosa, et al people with previous medical conditions, who fers an opportunity to accurately evaluate the risk have a higher probability of developing a serious factors in patients infected with SARS-CoV-2 illness3. This multimorbidity is usually defined as having comorbidities and whether these comor- the detection of two or more chronic conditions bidities are related to patient deterioration17. This in a single individual4. As a consequence of this determination could lead to a better ability to multimorbidity state, some studies have shown triage or monitor these patients, which could a relationship between in-hospital mortality and help healthcare providers to optimize resources comorbidity5-12. in the context of limited care supplies17. Indeed, this analysis could provide information about the Background/Justification for Study best way of managing patients with SARS-CoV-2 This is relevant in countries like Spain, based on their age, comorbidities and another where the present study was carried out. Due parameter in the future. to its demographic characteristics, with an age- ing population, the increase of comorbidities Objectives of Study is significant. This tendency to an increasingly The aim of the present study was to deter- ageing population appears in many regions of mine the prognostic factors for mortality and the world. The European Union (EU-28) is an intensive care unit (ICU) admission in patients example. With an estimated population of 512.4 with COVID-19 admitted in the aforementioned million on 1 January 2018, people aged 65 or hospitals. over represent 19.7% of the world’s population, with an increase of 2.6% in the last 10 years. Design and Methods Italy shows the highest percentage (22.6%)13. A retrospective observational study was car- In Spain, the situation is similar (19.1%) and ried out based on clinical data from a Spanish shows a relevant increase of octogenarians healthcare entity in the private sphere with imple- (6.1%) and centenarians (11 229 registered)14. mentation throughout the Spanish territory. Experts estimate that the percentage of people aged 65 or over in Spain will reach 25.2% by Setting, Sample, and Data Collection 203315. Attending to the probability of comor- The data was transferred after a request and bidity in elderly people, those data are relevant with the corresponding institutional and ethi- in the context of the SARS-CoV-2 pandemic, cal permissions. This entity represents a group since they represent a high-risk segment of the of hospitals, polyclinics and private health cen- population. It is known that the main cause of tres, which have made their databases related mortality in elderly people is cardiovascular to COVID-19 cases available to the scientific pathology (29.7%). On the other hand, fragility community. is closely related to advanced age and a higher A database that collected clinical information risk of adverse health events16. In this sense, a on 1987 patients who had accessed, between 5 recent study in Spain shows a higher prevalence February 2020 and 20 April 2020, the emergency of chronic cardiovascular and non-cardiovascu- services of the aforementioned private hospital lar diseases, wider use of polypharmacy and network and who were diagnosed with COVID-19 higher risk of fragility in elderly people16. For or who were suspicious for COVID-19 and await- these reasons, it seems necessary to take of age ing results were analyzed. and comorbidities into account when managing Diagnoses were coded following the Interna- patients in a COVID-19 pandemic context17. A tional Classification of Diseases, 10th Revision recent systematic review17 showed that comor- (ICD-10)18. Variables such as age, sex, date of hos- bidities, such as hypertension, cardiovascular pital admission, date of the emergency room visit disease, chronic kidney disease, diabetes mel- that led to admission, admission to ICU, length litus or acute cardiac and kidney injury, were of stay in ICU, medical discharge, destination of related to an increased disease severity and an discharged patients and deaths were analyzed. increased risk of COVID-19-related mortality. In addition, data related to vital signs (first and The comorbidities of patients with COVID-19 last records of temperature, oxygen saturation, were registered, together with other data such heart rate, and blood pressure) were analyzed. as vital constants and illness development. The Along the same lines, analytical parameters such analysis of the comorbidities allows to detect as blood creatinine, D-dimer, and glucose levels, mortality or intensive care risks. Concretely, it of- as well as partial pressure of oxygen (pO2), were 3378 Mortality and critical conditions in COVID-19 patients at private hospitals: weekend effect? analyzed. Once the data was received by the in- Results stitution, they were refined. Data from 1987 (N) patients were analyzed. Tools and Methods Of these, 60.3% (n = 1199) were men and 39.7% A statistical analysis was performed using (n = 788) were women. Of the total number of IBM SPSS Statistics version 25 (IBM Corp, Ar- patients, 54% (n = 1072) were assisted on the monk, NY, USA). In addition, the Charlson and weekend (Friday, Saturday or Sunday). Overall, Elixhauser indices were used to predict compli- 7.3% of the patients (n = 146) were admitted cations, in-hospital mortality or mortality19-21. The to the ICU. Considering an administrative loss Charlson and Elixhauser indices were calculated of 216 records (without data related to death or according to the comorbidities registered using survival), the percentage of deaths was 15.7% the “comorbidity” package of the free software R (n = 278); 79.8% (n = 1414) of patients were sent (version 3.5.0). home and 77 patients were transferred to another hospital or social health centre (4.3%). Data Analysis Concerning the symptoms of patients, breath- First, data for each variable was descriptively lessness appeared more frequently (54.2%, n = analyzed in terms of absolute frequencies, per- 1076), followed by fever (12.9%; n = 256), cold centages, and measures of central tendency. A symptoms (11.3%; n = 225), cough (6.8%; n = distribution analysis of the sample data was also 136), and malaise or general malaise (5.9%; n = carried out using the Kolmogorov-Smirnov test.